Tolson v. Avondale Industries, Inc.
| Decision Date | 03 June 1998 |
| Docket Number | No. 97-31029,97-31029 |
| Citation | 141 F.3d 604 |
| Parties | Gregory A. TOLSON, Plaintiff-Appellant, v. AVONDALE INDUSTRIES, INC., Avondale Industries, Inc., Shipyards Division, Avondale Health Plan and Avondale Industries, Inc., Shipyards Division, Group Insurance Plan, Defendants-Appellees. |
| Court | U.S. Court of Appeals — Fifth Circuit |
James Robert Hashek, New Orleans, La, for Plaintiff-Appellant.
Keith M. Pyburn, Jr., Carolyn A. Knox, McCalla, Thompson, Pyburn, Hymowitz & Shapiro, New Orleans, LA, for Defendants-Appellees.
Appeal from the United States District Court for the Eastern District of Louisiana.
Before WIENER, BARKSDALE and DeMOSS, Circuit Judges.
Despite Tolson's insistence to the contrary, the material facts of this case are undisputed. Tolson was employed by Avondale from 1981 through April 1987 and was a participant in and a qualified beneficiary of the Plans. He was diagnosed in December 1994 by Dr. Robert Perillo, a liver specialist at New Orleans' Ochsner Clinic and an approved medical provider under the AHP, as having "moderate chronic Hepatitis C, with mild but definite chronic active component." Tolson was successfully treated by Dr. Perillo in an experimental program using Interferon-Alpha 2a, and the AHP paid for all eligible medical charges and prescription drugs. The following May, Tolson applied to the GIP for weekly disability benefits on the basis of a statement from Dr. Perillo that Tolson suffered "Interferon-induced adverse effects (insomnia, fatigue) causing temporary disability." Following the GIP's approval of his application, Tolson started receiving weekly disability benefits. In August 1995, Tolson applied to the GIP for long-term disability benefits based on his chronic Hepatitis C. Four days later Tolson was released by Dr. Perillo to return to work. Even though the physician's statement said that Tolson was not totally disabled, he was approved for long-term benefits for 21 days, being the number of days between the end of his 90-day elimination period and the date of his return to work. Tolson received no other long-term disability benefits under the GIP.
The recommencement of Tolson's work was unremarkable until March 1996, when Dr. Gerald Heintz, a psychiatrist with Ochsner to whom Tolson had been referred by Dr. Perillo, diagnosed Tolson as suffering from "major depression" and treated him for that condition. According to Tolson, his depression is a secondary symptom resulting directly from his Hepatitis and the Interferon treatment he received for it.
The following month, almost eight months after he had returned to work from disability leave, Tolson quit his job. He blamed his depression for his inability to continue working.
The entire documentation for each of the Plans is contained in its Summary Plan Description ("SPD"); there are no separate trust indentures. The AHP provides comprehensive health care benefits for eligible employees and their beneficiaries, covering medical costs incurred in conformity with that plan's requirements. In the AHP, coverage of treatment of mental conditions is limited as follows:
a) Introduction:
Note in particular that covered treatment for Mental and Nervous conditions or Substance Abuse will be provided only by West Jefferson Behavioral Medicine Center ["WJBMC"].
b) Benefit Limitations Note: Coverage for Mental and Nervous conditions is provided ONLY by [WJBMC] and is subject to different limitations, deductibles and co-payments.
c) Summary of Benefits:
In order that treatment for mental and nervous conditions be covered by the [AHP], treatment must be pre-certified and provided by [WJBMC]. There is no plan benefit for services received from other sources.
Parallel provisions limiting coverage of disability by reason of mental conditions under the GIP are as follows:
a) Weekly disability Benefits (Non-Occupational)--Benefit Limitations
....
Also, benefits will not be payable for disability because of mental or nervous disorders unless hospitalized. If hospitalized, then later discharged, benefits will not continue beyond 30 days following discharge.
b) Long-Term Disability Benefits--Benefit Limitations
....
Also, benefits will not be payable for disability because of mental or nervous disorders, unless hospitalized. If hospitalized, then later discharged, benefits will not continue beyond 30 days following discharge.
Both plans establish an ERISA Review Committee (the "Committee") and endow the Committee with discretionary powers to interpret the terms of the Plans and to evaluate claims for benefits. Among other things, those provisions specify that the Committee has "sole and exclusive discretion and power to grant and/or deny any and all claims for benefits, and construe any and all issues of Plan interpretation and/or facts or issues relating to eligibility for benefits." "All findings, decisions, and/or determinations of any type made by the [Committee] shall not be disturbed unless the [Committee] act(s) in an arbitrary and/or capricious manner or abuses the discretion and powers conferred by the Plan's sponsor."
After he quit working, Tolson claimed coverage of his treatment for a "major depressive disorder" and sought disability benefits on that basis as well. As no part of Tolson's treatment for depression took place at WJMBC, the plan administrator for the AHP denied his claim for psychological treatment. Similarly, his application to the GIP for long-term disability benefits was denied because he was never hospitalized for his depression. An additional road block to Tolson's coverage is the fact that Dr. Heintz is not on the list of approved referral providers. 3 Tolson's claim for coverage of psychological treatment was denied because it was not pre-certified and none of it was provided by WJBMC. Likewise, his claim for disability benefits was denied because he was never hospitalized for his nervous or mental condition. The Plans classified Tolson's claims as stemming from a distinct and separate "mental or nervous disorder or condition," terms that, Tolson notes, are not defined in the Plans. He appealed the denial of his claim, but the Committee unanimously upheld denial.
Tolson sued in March 1997, alleging wrongful denial of benefits or, in the alternative, breach of the fiduciary duty to avoid misrepresenting the terms of available coverage. His complaint asserted that he was improperly denied payment of medical claims in connection with his treatment for depression under the AHP, and was improperly denied payment of disability benefits under the GIP. He grounded his alternative breach of fiduciary claim in the alleged misrepresentation of the terms of the Plans, both of which are employee welfare benefit plans governed by ERISA.
After some preliminary procedural skirmishing, which included the Plans' filing a motion to dismiss and Tolson's amendment of his complaint, the defendants filed a motion for summary judgment, and Tolson filed an opposition. Shortly thereafter, the district court granted the Plans' motion and entered
judgment dismissing Tolson's claims and assessing costs to him. Tolson filed a motion for review of the taxation of costs which the court denied. Tolson timely filed a notice of appeal.
All grants of summary judgment are reviewed de novo. 4 "Whether the district court employed the appropriate standard in reviewing an eligibility determination made by an ERISA plan administrator is a question of law." 5 "Therefore, we review the district court's decision de novo." 6 When an ERISA plan vests its administrator or fiduciary with discretionary authority to determine eligibility for benefits or to construe the terms or the plan, or both, our standard of review is abuse of discretion. 7 There is no question but that the language of...
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