The Sunbeam-Oster Company, Inc. Group Benefits Plan for Salaried and Non-Bargaining Hourly Employees v. Leonard Whitehurst, Jr.

102 F.3d 1368, 28 Employee Benefits Cas. (BNA) 1182, 1996 U.S. App. LEXIS 33357, 1996 WL 731553
CourtCourt of Appeals for the Fifth Circuit
DecidedDecember 19, 1996
Docket95-31269
StatusPublished
Cited by93 cases

This text of 102 F.3d 1368 (The Sunbeam-Oster Company, Inc. Group Benefits Plan for Salaried and Non-Bargaining Hourly Employees v. Leonard Whitehurst, Jr.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fifth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
The Sunbeam-Oster Company, Inc. Group Benefits Plan for Salaried and Non-Bargaining Hourly Employees v. Leonard Whitehurst, Jr., 102 F.3d 1368, 28 Employee Benefits Cas. (BNA) 1182, 1996 U.S. App. LEXIS 33357, 1996 WL 731553 (5th Cir. 1996).

Opinion

WIENER, Circuit Judge:

Resolution of the principal issues presented by this appeal requires the construction and application of reimbursement and subro-gation provisions of the Plaintiff-Appellant Sunbeam-Oster Company, Inc. Group Benefits Plan for Salaried and Non Bargaining Hourly Employees (the Plan), a self-funded welfare benefit plan under the Employee Retirement Income Security Act of 1974 (ERISA). 1 This litigation was spawned when Defendant-Appellee Leonard Whitehurst, Jr.—a plan beneficiary who had been seriously injured in a motor vehicle accident unrelated to his employment and whose resulting six-figure medical expenses were paid by the Plan—refused to reimburse the Plan for payments it made on his behalf, even though he had recovered more than sufficient funds with which to do so from a settlement with third parties. For the reasons hereafter explained, we reverse the district court’s judgment favorable to Whitehurst and hold that the plain language of the Plan was neither silent nor ambiguous but, at least by unmistakable implication, embodied a “first dollar” priority right in favor of the Plan (hereafter “Plan Priority”) to be reimbursed from the proceeds of a beneficiary’s recovery.

I

FACTS AND PROCEEDINGS

A The Accident; The Plan; Whitehurst’s Lawsuit

Whitehurst, a long-time employee of Sunbeam-Oster Company, Inc. (Sunbeam), was *1370 severely injured in a non-work related acei-dent when an eighteen-wheel tractor/trailer (the rig) crossed the centerline of a rural Louisiana highway and collided with his car. Whitehurst’s extreme injuries necessitated extensive surgery, hospitalization, and rehabilitation.

Whitehurst was covered by the Plan as a dependent under a family coverage arrangement in which his wife, also a Sunbeam employee, was the participant and paid the premiums. As a covered dependant he was a beneficiary of the Plan and thus was entitled to have his medical bills — totaling approximately $137,000 as of the time briefs were filed in this appeal—paid by the Plan. The Plan was a self-funded, participant-contributory, employee welfare benefits plan governed by ERISA, and provided health and medical benefits on a voluntary basis to thousands of employees of Sunbeam and their designated beneficiaries. 2 Participants were required to make contributions to the Plan, but as their total contributions were insufficient to pay the aggregate costs of covered services, claims were largely paid from the general assets of Sunbeam. Blue Cross and Blue Shield of Mississippi, Inc. (Blue Cross) served as the “third party administrator” of the Plan. In that capacity, it processed the claims of Plan participants and their beneficiaries.

After his accident, Whitehurst hired a lawyer and, together with his wife and minor child, both of whom had witnessed the critically injured Whitehurst being pried from his car at the scene of the accident, filed a state court negligence suit against the driver of the rig, its owner, and the owner’s insurer. They asserted claims for Whitehurst’s injuries and his wife and son’s loss of consortium. 3

The Whitehursts’ attorney finally informed the Plan of this lawsuit when settlement appeared imminent, and requested itemized medical expense statements so that he might “protect [the Plan’s] interests.” 4 Partly in reliance on this communication from White-hurst’s counsel, the Plan chose not to intervene in the suit or participate in any settlement negotiations.

The Whitehursts ultimately settled all their tort claims arising from the accident jointly for $500,000, the limit of the rig owner’s insurance policy, plus $9,000 in property damages. The settlement agreement neither apportioned the recovery among the plaintiffs nor itemized the $500,000 lump sum as to medical expenses or, for that matter, any other category of damages. In that agreement, however, the Whitehursts expressly absolved the defendants and agreed to hold them harmless from liability for “all medical expenses, hospital expenses and hens incurred by and in connection with any medical treatment rendered to [Whitehurst].”

B. The Reimbursement Provisions of the Plan; the Plan’s Lawsuit

In compliance with requirements under ERISA, Sunbeam had filed the original plan document for the Plan with the Department of Labor about two years before White-hurst’s accident. As is typically the case with ERISA self-funded welfare benefit plans, the document filed with the Department was not a formal trust indenture (here, there was none), but rather an employee benefits handbook, a “Summary Plan Description” (SPD) in ERISA parlance. As discussed more fully below, ERISA insists that the SPD be couched in ordinary conversational terms, understandable by the average reasonable employee, and not in verbose “legalese” or “insurance speak.” 5 The *1371 health care benefits section of the Plan’s SPD contained a number of “General Exclusions,” one of which was for:

charges for which payment or reimbursement is received by or for the individual as a result of a legal action or settlement (unless you [the participant or beneficiary] sign the necessary documents authorizing the deduction of any overpayment from your benefit, wage and pension payments).

That section of the SPD also contained a subsection titled “Subrogation,” which, stated in full, provided:

Subrogation allows the Plan to recover duplicate benefit amounts. For example, if you are injured by another individual and incur $1000 in covered expenses — and you sue that individual and recover $1000 — the Sunbeam-Oster Plan does not pay benefits for those expenses. If the plan has already paid benefits, it has the right to recover payment from you. This also applies to benefits paid through the Plan’s COB [Coordination of Benefit] feature.
The subrogation and COB features only apply for group insurance plans (not to individually purchased coverage) — including automobile no-fault programs.

Several months prior to Whitehurst’s accident, the Plan issued to plan participants (but did not file with the Department of Labor) an “Insert and Summary of Material Modification” to replace the above quoted “Subrogation” subsection. This modification, titled “Subrogation and Reimbursement Provisions,” stated in pertinent part:

The Plan has subrogation and reimbursement provisions which allow the Plan to recover for benefits it pays which are duplicated from another source. The Plan provides an automatic lien on any funds subject to reimbursement or subrogation.
Reimbursement gives the Plan the right to collect from you money that you receive in a settlement or lawsuit that covers expenses that the Plan has already paid for....
Reimbursement Example—You are injured and receive $1,000 in covered expenses from the Plan. The person who caused your injury agrees to settle with y°u an^ pays you the $1,000.

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Bluebook (online)
102 F.3d 1368, 28 Employee Benefits Cas. (BNA) 1182, 1996 U.S. App. LEXIS 33357, 1996 WL 731553, Counsel Stack Legal Research, https://law.counselstack.com/opinion/the-sunbeam-oster-company-inc-group-benefits-plan-for-salaried-and-ca5-1996.