Tiemeyer v. Community Mutual Insurance

8 F.3d 1094
CourtCourt of Appeals for the Sixth Circuit
DecidedNovember 3, 1993
DocketNos. 92-3415, 92-3528 and 92-3529
StatusPublished
Cited by24 cases

This text of 8 F.3d 1094 (Tiemeyer v. Community Mutual Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Tiemeyer v. Community Mutual Insurance, 8 F.3d 1094 (6th Cir. 1993).

Opinions

CONTIE, Senior Circuit Judge.

I.

Plaintiff-appellant cross-appellee Donna Tiemeyer (“Tiemeyer”) was an employee of defendant-appellee cross-appellant Children’s Hospital Medical Center (“Children’s Hospital”) on October 13, 1987, when she learned of the possibility of a private adoption of triplets yet to be born. She and her husband immediately contacted an attorney to represent them in securing the children. That same day, Tiemeyer contacted the benefits department at the Children’s Hospital to determine the children’s eligibility under “The Children’s Hospital Medical Center Blue Cross, Blue Shield, and Major Medical Plan for Regular Full-Time and Part-Time Employees” (the “Plan”).

On December 29, 1987, the male triplets were born at University Hospital in Cincinnati. The boys were two months premature, severely underweight and underdeveloped, and quite ill. Immediately after birth, the children were placed in the critical care unit of University Hospital. Because of their varying weights at birth (ranging from 1 lb. 15 oz., to 2 lbs. 12 oz.) and differing medical problems, the boys progressed at varying rates. Plaintiff-appellant cross-appellee Geoffrey Tiemeyer was discharged from Children’s Hospital on March 2,1988. Plaintiff-appellant cross-appellee Joshua Tiemeyer was discharged on April 23, 1988. Plaintiff-appellant cross-appellee Zachary Tiemeyer was discharged on May 13, 1988.

On December 31, 1987, two days after the triplets were born, the Tiemeyers’ attorney filed a preplacement application in the Hamilton County Court of Common Pleas, Probate Division. A report on the proposed placement, completed by the Children’s Protective Service, was sent to the court on January 4, 1988.

On January 15,1988, the triplets’ biological mother filed an Application for Approval of Placement. That same day, the Tiemeyers filed their Petition for Adoption. On the basis of such filings, an Entry Approving Placement was signed and journalized on January 15, 1988, by the Probate Court referee.

Tiemeyer applied for dependent coverage under the Plan for the triplets effective as of the date of their placement, January 15, 1988. Defendant-appellee cross-appellant Community Mutual Insurance Company [1096]*1096(“Community Mutual”), the Plan’s administrator, denied the Tiemeyers’ application because it considered the children’s “adoption date” to be the date that the children “established residence” with the policyholder. Because the children were not physically removed from the hospital prior to January 15, 1988, Community Mutual concluded that the children had not established residency with the Tiemeyers.

On April 11, 1988, the Hamilton County Probate Court conducted a hearing on the Tiemeyers’ Petition for Adoption and granted an Interlocutory Order of Adoption. On November 3, 1988, the Hamilton County Probate Court entered its Final Decree of Adoption.

Tiemeyer continued to appeal Community Mutual’s decision through a series of denials. Meanwhile, University Hospital filed suit against the Tiemeyers in the Hamilton County Court of Common Pleas on December 15, 1989, seeking $289,108.99 plus interest and court costs, for nonpayment of hospital and related medical expenses incurred prior to the children’s discharge dates.

Plaintiffs-appellants cross-appellees Donna, Thomas, Geoffrey, Zachary and Joshua Tiemeyer (collectively the “appellants” or “Tiemeyers”) initiated this action against Community Mutual and the Children’s Hospital on July 6, 1990, alleging breach of contract, violation of the Tiemeyers’ civil rights, and a claim pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), as amended, Title I of which covers any employee benefit plan maintained “by any employer engaged in commerce or in any industry or activity affecting commerce” unless expressly exempted. 29 U.S.C. § 1003(a)(1). Pursuant to 29 U.S.C. § 1132(a)(1)(B), a participant or beneficiary may bring a civil action “to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(g)(1) authorizes the court to “allow a reasonable attorney’s fee and costs of action to either party.”

On February 12, 1991, the Tiemeyers amended their complaint to include the Plan as a defendant. On March 6, 1991, Community Mutual, the Children’s Hospital, and the Plan moved to strike counts one (breach of contract) and three (violation of civil rights) of the Tiemeyers’ First Amended Complaint. On April 23, 1991, the district court granted the motion, leaving only the ERISA cause of action. On October 28, 1991, all parties filed simultaneous motions for summary judgment and a Stipulated Statement of Facts.

On April 16, 1992, the district court, 789 F.Supp. 894, granted summary judgment to the Tiemeyers and ordered the payment of benefits, but denied the Tiemeyers’ request for attorney fees, costs and prejudgment interest:

Community Mutual’s decision to deny benefits is based upon the Tiemeyer infants’ inability to satisfy an adoption date residency requirement. This requirement consists of a dependent status and a physical presence in the Tiemeyer home:
Inasmuch as all three children have been inpatients at Children’s since birth and are not primarily dependent upon her for support, it is impossible for them to have established residence with Ms. Tiemeyer prior to the date Ms. Tiemeyer’s Petition for Adoption was filed, and such impossibility will continue for as long as the children remain hospitalized.
The Community Mutual Appeals Committee upheld this denial on the same ground. Upon a review of the record before the administrator this Court disagrees with the decision to deny benefit coverage.
On January 15, 1988, the natural mother consented to give the triplets up for adoption and the Tiemeyers filed the Petition for Adoption. On this date, in accordance with the Ohio Revised Code, the Tiemey-ers assumed the responsibility for paying the physician and hospital expenses incurred in connection with the birth of the triplets, physician expenses incurred in connection with prenatal care or confinement, and agency expenses incurred in connection with the adoption. As of January 15, 1988, the triplets were primarily, if not totally, dependent upon the Tiemeyers for support.
[1097]*1097Under the Plan a participant’s unmarried dependent child between 19 and 25 years old, unmanned dependent child who is a full-time student, or dependent disabled child may gain coverage by satisfying a residency requirement. In each of these situations residency is not interpreted as requiring a physical presence in the Plan participant’s home. The Defendants contend that this interpretation is justified because there is “a valid distinction to be made in that at one time [these classes of dependent children] actually lived at the subscribers’ home prior to leaving.”
The Defendants’ contention that the triplets established residency on their respective hospital discharge dates also conflicts •with Ohio law....

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8 F.3d 1094, Counsel Stack Legal Research, https://law.counselstack.com/opinion/tiemeyer-v-community-mutual-insurance-ca6-1993.