Tiemeyer v. Community Mutual Insurance

789 F. Supp. 894, 15 Employee Benefits Cas. (BNA) 2218, 1992 U.S. Dist. LEXIS 5149, 1992 WL 80130
CourtDistrict Court, S.D. Ohio
DecidedApril 16, 1992
DocketNo. C-1-90-509
StatusPublished
Cited by3 cases

This text of 789 F. Supp. 894 (Tiemeyer v. Community Mutual Insurance) is published on Counsel Stack Legal Research, covering District Court, S.D. Ohio 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, 789 F. Supp. 894, 15 Employee Benefits Cas. (BNA) 2218, 1992 U.S. Dist. LEXIS 5149, 1992 WL 80130 (S.D. Ohio 1992).

Opinion

ORDER

CARL B. RUBIN, District Judge.

This matter is before the Court upon cross-motions for summary judgment (documents 36, 37 and 38). Fed.R.Civ.P. 56(c). The Plaintiffs assert a claim under the Employee Retirement Income Security Act of 1974 (ERISA) to recover benefits allegedly due to them as participants in an employee welfare benefit plan, 29 U.S.C. § 1132(a)(1)(B), and for an alleged breach of fiduciary duty, 29 U.S.C. § 1132(a)(2). In accordance with Federal Rule of Civil Procedure 52, this Court herewith submits its Findings of Fact, Opinion and Conclusions of Law.

FINDINGS OF FACT

Donna Tiemeyer (Tiemeyer), an employee of the Children’s Hospital Medical Center (CHMC), and her husband Thomas Tiemeyer were provided family coverage through CHMC under the a group policy— the CHMC Blue Cross Blue Shield and Major Medical Plan for Regular Full-Time and Part-Time Employees (Plan). The Plan was purchased from the Community Mutual Insurance Company (Community Mutual or CMIC). CHMC administered the Plan. Community Mutual was responsible for enrollment administration and the day-to-day claims. Stipulated Statement of Facts, at 2, Us 6, 7 and 9, document 39.

On October 13, 1987, a co-worker informed Tiemeyer of a pregnant young woman who wanted to give her expected triplets up for adoption. Interested in the possibility of adopting the triplets, Tiemeyer consulted the Summary Plan Description booklet (SPD or “book”) issued to the Plan’s participants. Deposition of Donna Tiemeyer, at 32-33; Stipulated Statement of Facts, at 3 Us 11-12, document 39. Under the heading ELIGIBILITY INFORMATION — Who is eligible the SPD states that “[eligible children are your [a Plan participant’s] unmarried children who have not reached the age of 19.” Stipulated Statement of Facts, Exhibit 3 at 4, document 39. (clarification added).

Also on October 13, 1987, Tiemeyer contacted CHMC benefits specialist Mary Gavin regarding coverage for the triplets. Deposition of Donna Tiemeyer, at 12, 18, 32-33; Stipulated Statement of Facts, at 3, Us 11-12, document 39. Gavin informed Tiemeyer of Community Mutual’s policy regarding coverage of an adopted child. Gavin told Tiemeyer that she would check to see if this policy had changed and get back to her. Before the triplets were born Gavin called Tiemeyer and read to her the applicable policy from the Administrative manual. Deposition of Donna Tiemeyer, at 70-72; Deposition of Mary K. Gavin, at 91-97. That policy provides:

What to do when an employee adds a dependent
In the case of child adoption, if the application is received within 30 days of the adoption, the adoption date becomes effective date of the coverage. The adoption date is the date the child established residence with the subscriber or the date the petition for adoption is filed, which ever occurs last.

Stipulated Statement of Facts, Exhibit 5 at 14, document 39.

On December 29, 1987, the unidentified young woman gave birth to triplets at the University of Cincinnati Hospital. The infants incurred serious medical problems associated with their premature birth and were placed in the Hospital’s critical care unit. Stipulated Statement of Facts, at 3 1113, document 39; Plaintiffs’ Motion for Summary Judgment, Exhibit I, document 36.

During this time period David A. Garretson, an attorney handling the private adoption for the Tiemeyers, discussed the situation with Community Mutual attorneys Amy Zeldin and Ray Umstead. In a January 14, 1988, letter Zeldin informed Garretson that “we are in the process of reviewing Donna Tiemeyer’s coverage so that we may properly advise you regarding [897]*897coverage for the triplets Ms. Tiemeyer is adopting.” Stipulated Statement of Facts, Exhibit 7, document 39.

On January 15, 1988, the Tiemeyer’s filed a petition in the Hamilton County Court of Common Pleas, Probate Division, for the adoption of Joshua William Tiemeyer, Zachary Gene Tiemeyer, and Geoffrey Robert Tiemeyer. The Probate Division issued an Interlocutory Order of Adoption on April 11, 1988, and a granted a Final Decree of Adoption on November 3, 1988. Plaintiffs’ Motion for Summary Judgment, Exhibit B, document 36; Stipulated Statement of Facts, Exhibit 6, document 39.

Hours after filing the adoption petition Tiemeyer filed an application with CHMC to add the triplets as her dependents under the Plan. The effective date to add the triplets is recorded as “1/15/88 The asterisk was notated by Tiemeyer at Gavin’s request to indicate “or as soon as poss [possible] legal date.” Stipulated Statement of Facts, Exhibit 4, document 39. (clarification added).

Zeldin “formally and explicitly advised” the Tiemeyers in a January 19,1988, letter to Garretson that the triplets were not covered under the Plan because they failed to satisfy the adoption date residency requirement. This letter was also sent to Gavin. CHMC’s Motion for Summary Judgment, at 4, document 38; Community Mutual’s Motion for Summary Judgment, at 9, document 37; Stipulated Statement of Facts, Exhibit 7, document 39.

The Tiemeyer’s appealed the coverage denial to the Community Mutual Corporate Appeals Committee. The Committee denied the appeal. Corresponding to the hospital discharge date of each Tiemeyer infant the Committee stated that “Jeffery [sic] established his residency in the Tiemeyer household on March 2, 1988; Joshua on April 23, 1988; and Zachary on May 13, 1988. Therefore, these are the dates on which the criteria for coverage of adoptive children were satisfied.” Stipulated Statement of Facts, Exhibits 8 and 9, document 39.

The Tiemeyers instituted this action on June 6, 1990. Complaint, at 1, document 1. The Plaintiffs claim that the health care expenses incurred by the Tiemeyer infants total $413,470.00. First Amended Complaint, at ¶ 14 and Exhibit C, document 13; Stipulated Statement of Facts, Exhibit J, document 39.

OPINION

Summary Judgment

The summary judgment procedure under Federal Rule of Civil Procedure 56 is designed to secure a just, speedy, and inexpensive determination of any action. Celotex Corp. v. Catrett, 477 U.S. 317, 327, 106 S.Ct. 2548, 2554-55, 91 L.Ed.2d 265 (1986). Rule 56(c) permits the Court to grant summary judgment as a matter of law only after the moving party has identified as the basis of its motion “the pleadings, depositions, answers to interrogatories, and admission on file, together with the affidavits, if any” which demonstrate the absence of any genuine issue of material fact. Celotex, 477 U.S. at 323, 106 S.Ct. at 2552-53.

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Related

Tiemeyer v. Community Mutual Insurance
8 F.3d 1094 (Sixth Circuit, 1993)
Whisman v. Robbins
810 F. Supp. 936 (S.D. Ohio, 1992)

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Bluebook (online)
789 F. Supp. 894, 15 Employee Benefits Cas. (BNA) 2218, 1992 U.S. Dist. LEXIS 5149, 1992 WL 80130, Counsel Stack Legal Research, https://law.counselstack.com/opinion/tiemeyer-v-community-mutual-insurance-ohsd-1992.