Skelton v. Lowen

669 F. Supp. 133, 1987 U.S. Dist. LEXIS 8497
District Court, E.D. Virginia·Decided September 16, 1987·No. Civ. A. No. 86-855-N·Published·Cited by 2 cases

Opinion

ORDER

CLARKE, District Judge.

This matter comes before the Court on Motions for Summary Judgment filed by both plaintiff and defendants. The parties have filed responsive briefs and have stipulated the facts and exhibits. Accordingly, this matter is ripe for disposition.

Defendants are the Chairman and Board of Trustees of the Master, Mates & Pilots Health & Benefit Plan (the “Health Plan”). The Health Plan was established in 1950 pursuant to Section 302(c)(5) of the Labor Management Relations Act, 29 U.S.C. § 186(c)(5). It is a multi-employer welfare benefit plan that resulted from collective bargaining between the International Organization of Masters, Mates & Pilots and various maritime employers. Plaintiff’s decedent, Dwight Skelton (“Skelton”), was employed as a licensed deck officer by one of the Health Plan’s contributing employers in 1964. He subsequently became entitled to coverage under the Plan. He continued to work as a licensed deck officer for various contributing employers until April, 1982 (except for a three-and-a-half year period when he was temporarily disabled). On April 19, 1982, Skelton was hospitalized with recurrent Hodgkins disease and became totally and permanently disabled.

[134]*134Between April 19, 1982 and August 18, 1983, the Health Plan paid Skelton medical expense benefits in accordance with the Rules and Regulations of the Health Plan (the “Rules and Regulations”). The payment of these benefits is not in dispute.

Between August 19, 1983 and Skelton's death on June 12, 1985, Skelton and his counsel continued to submit claims for medical expense benefits, but these claims were denied by the Health Plan. In September 1984, Skelton wrote to the Health Plan inquiring as to his eligibility for a disability pension. Skelton was informed that he was ineligible for a disability pension. This determination is not in dispute. A month later, Skelton wrote to the Health Plan inquiring as to his eligibility for medical expense benefits, and in addition, for temporary long-term disability benefits. He was advised that he was ineligible for either type of benefits.

In November of 1986, plaintiff, as administratrix of Skelton’s estate, brought an action alleging that defendants had violated Section 302(c)(5) of the Labor Management Relations Act by failing to pay Skel-ton medical expense benefits from August 19, 1983 until June 12, 1985 and temporary long-term disability benefits from April 19, 1983 until June 12, 1985.

Plaintiffs claim challenges defendants’ interpretation of the Rules and Regulations as they pertain to medical expense benefits and temporary long-term disability benefits. At the outset, the Court recognizes that it can overturn defendant Trustees’ interpretation of the Rules and Regulations only if such interpretation was arbitrary and capricious. See Morgan v. Mullins, 643 F.2d 1320, 1321 (8th Cir.1981); Rueda v. Seafarers International Union of North America, 576 F.2d 939, 943 (1st Cir.1978); Snyder v. Titus, 513 F.Supp. 926, 932 (E.D.Va.1981). Under this standard, the Court cannot substitute its own interpretation of the Rules and Regulations for that of defendants; instead, the Court must limit its review to whether the defendants’ interpretation was rational and reasonable. See Snyder, 513 F.Supp. at 932.

The Court first takes up defendants’ interpretation of the Health Plan’s medical expense benefits provision. The Rules and Regulations, Article VI, Section 1 provide:

Section 1. Major Medical Expense Benefits
If any eligible Employee or eligible Dependent incurs Covered Medical Expenses (as defined herein) a benefit shall be reimbursable to the Employee, for such expenses so incurred in an amount equal to 80% of the amount by which the sum of all Covered Medical Expenses which are incurred by the Employee and his Dependents in a calendar year exceeds the deductible amount of $100.00 on the date on which the Employee or Dependent receives or is furnished with services or supplies in connection with which such expense is incurred.
Effective June 16, 1981, all out-of-pocket covered expenses incurred during an 18-month period or incurred as the result of one illness or injury in excess of $1,500, shall be reimbursed 100% under Major Medical. (Amendment No. 70 — Adopted 12/4/81).

Exhibit B at 77. Plaintiff asserts that this section entitled Skelton to medical expense benefits from August 19, 1983 to June 12, 1985.

Defendants, however, contend that these medical expense benefits are not triggered unless a claimant is an “eligible Employee.” Article I, Section 14 defines an “Eligible Employee” as “an Employee who meets the conditions of eligibility set forth in Article II.” Exhibit B at 37. Article II, Section l(a)-(d)(l) goes on to provide:

Section 1. Active Employees
(a) Each Active Employee who has been on the payroll of one or more Employers shall become eligible for benefits hereunder on the date such Employee completes thirty days on the payroll of one or more Employers within any period of six consecutive calendar months. However, an Active Employee shall become eligible from the date he proceeds to sea on a voyage contemplated to exceed thirty days.
[135]*135Each day of employment as a Relief Mate shall count the same as other employment for the purpose of determining eligibility. (Amendment No. 50— Adopted January 25, 1973).
(b) Employment by an Employer, after the active Employee has been advised by the Plan through the Union that such Employer is delinquent in its contributions to the Plan, shall not be considered days on the payroll for the purpose of determining or continuing eligibility.
(c) For the purpose of determining eligibility hereunder, days of Disability shall count as days on payroll of one or more Employers upon the following conditions:
(1) For the purpose of establishing eligibility, the days of Disability are within six (6) consecutive months of the last day of the Active Employee was actually on such payroll.
(2) For the purpose of continuing eligibility, each day of Disability shall count as a day on such payroll, subject to the limitations set forth in Sub-Section (d) of this Article II.
(d) The eligibility of an Active Employee shall terminate on the earliest of the following dates:
(1) The last day of the period of six (6) consecutive months starting with the last day of a period of thirty days or more, in any six (6) consecutive months, for which the Active Employee was on the payroll of one or more Employers; provided, that eligibility which is based in whole or in part upon days of Disability shall in no event be continued for more than one (1) year from the last day of Disability which occurred within six (6) consecutive months of the last day the Active Employee was actually on such payroll.

Exhibit B at 38-39.

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Skelton v. Lowen, 669 F. Supp. 133, 1987 U.S. Dist. LEXIS 8497 (E.D. Va. 1987).

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