Buttram v. Central States, Southeast and Southwest Areas Health and Welfare Fund

• Decision Date: 16 February 1996
• Docket Number: No. 95-2372,95-2372
• Citation: 76 F.3d 896
• Parties: Pens. Plan Guide P 23921V Jerry BUTTRAM; Juston Buttram, Appellants, v. CENTRAL STATES, SOUTHEAST AND SOUTHWEST AREAS HEALTH AND WELFARE FUND, Appellee. CENTRAL STATES, SOUTHEAST AND SOUTHWEST AREAS HEALTH AND WELFARE FUND, Trustees of an Illinois Trust, Appellee, v. FORD MOTOR COMPANY, a Delaware corporation; Elmer C. Oberhellmann, Defendants, Jerry Buttram; Juston Buttram, Appellants.
• Court: U.S. Court of Appeals — Eighth Circuit

Page 896

76 F.3d 896

Pens. Plan Guide P 23921V

Jerry BUTTRAM; Juston Buttram, Appellants, v. CENTRAL STATES, SOUTHEAST AND SOUTHWEST AREAS HEALTH AND WELFARE FUND, Appellee.

CENTRAL STATES, SOUTHEAST AND SOUTHWEST AREAS HEALTH AND WELFARE FUND, Trustees of an Illinois Trust, Appellee, v. FORD MOTOR COMPANY, a Delaware corporation; Elmer C.

Oberhellmann, Defendants,

Jerry Buttram; Juston Buttram, Appellants.

No. 95-2372.

United States Court of Appeals,

Eighth Circuit.

Submitted Dec. 12, 1995.

Decided Feb. 16, 1996.

Appeal from the United States District Court for the Eastern District of Missouri; George F. Gunn, Jr., U.S.D.C. Judge.

Michael A. Gross, St. Louis, Missouri, argued, for appellants.

Francis J. Carey, Rosemont, Illinois, for appellee.

Before MAGILL, GOODWIN, ^* and MURPHY, Circuit Judges.

MAGILL, Circuit Judge.

Jerry Buttram appeals the district court's ¹ grant of summary judgment to Central States in this action governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1132(a)(1)(B). Buttram alleged that Central States improperly denied him reimbursement for home nursing care under Central States' employee health benefits plan. Because the benefits plan gave the plan administrator discretionary interpretive authority and the administrator's plan interpretation denying benefits was reasonable, we affirm.

I.

Jerry Buttram's son, Juston, suffered a severe spinal cord injury in an automobile accident on August 17, 1984, leaving him with quadriplegia. Juston received medical treatment at Freeman Hospital and St. John's Hospital in Missouri and at Craig Rehabilitation Hospital in Colorado, before returning home in 1985. Because Jerry Buttram's employer contributed to Central States' Health and Welfare Fund, Buttram was reimbursed $226,083.45 through February 1989 to cover the costs of Juston's hospitalization and institutional care.

Jerry Buttram asked Central States to pay for home nursing care in 1985 and again in late 1987, but in 1988 Central States denied this request. Buttram was entitled to three levels of review of this decision. The first-level appeal was initiated by the Buttrams and apparently denied; although Central States normally offers a written explanation to the applicant and notifies the applicant of the right to further appeal this decision, there is no proof that such notice was ever sent to Buttram. Because Buttram did not receive notice of his right to further review, his claims were not reviewed at a second-level appeal.

Nothing more was heard on this issue until 1993. In the interim, Buttram filed suit in 1989 against Central States, arguing, inter alia, that Central States impermissibly denied reimbursement to the Buttrams for the cost of renovations to their home and van, needed to accommodate Juston. In 1993, Buttram amended this complaint to include a claim for reimbursement for home nursing services provided by Virginia Buttram, Juston's mother. These services included help with hygiene, dressing, eating, and other daily living acts.

The magistrate judge ordered Buttram to pursue administrative remedies and submit his claims to the plan trustees. In evaluating the claim for benefits, the plan trustees relied on two reports, dated September 9, 1993 and February 3, 1994, written by Dr. W.B. Buckingham, the plan's reviewing physician. Dr. Buckingham noted that "[t]he nature of a spinal cord transection is total and permanent, and there is no known medical or surgical procedure that will restore function below the level of transection." Appellant's App. at 143. Any services rendered after Juston's discharge from Craig Hospital could not restore any function and thus should be considered custodial services. Id. Dr. Buckingham further noted that the care at issue in this case, including help with feeding, dressing, and hygiene, is not generally considered medical treatment, but rather is part of the management of these patients by the family caregivers. Dr. Buckingham analogized to the care given to an infant which, while important to the health of the infant, is not considered to be "medical care" as that term is commonly used.

The plan trustee also reviewed evidence, submitted by Buttram, that the care given by Virginia Buttram had helped to improve the mental and physical condition of Juston. Specifically, to the extent that the care permitted Juston to leave his home and interact with his surroundings, it ensured that Juston would be able to enjoy psychologically rewarding activities and lead a long and productive life. However, even Dr. Simowitz, one of Juston's treating physicians, conceded that Juston's physical condition was irreversible and that the care given by Virginia Buttram only prevented further debilitation. Dr. Simowitz did note, though, that to the extent that such care prevented disease and infection, it could "broadly" be considered "medical treatment."

On February 22, 1994, the trustees reviewed, and rejected, the claim for home nursing services. ² The trustees based this decision on Plan Sections 1.24(a)(3) (prohibiting reimbursement for medical care rendered by a patient's family member); Plan Section 4.02 (prohibiting reimbursement for care that is not standard medical care); and, for care given after January 1, 1998, Plan Section 4.16 (prohibiting reimbursement for custodial care, as defined by Plan Section 1.18). ³ The trustees noted that the care given by Virginia Buttram was analogous to the care given to an infant, which, although necessary, would not lessen Juston's physical infirmities.

The district court upheld this denial of benefits. ⁴ Applying an abuse of discretion standard of review, the district court concluded that Central States' interpretation of its plan to exclude the nursing services was reasonable. Further, performing a precautionary de novo review of the denial, the court held that the action was proper. This appeal followed.

II.

While ERISA itself does not specify the standard of review for a plan administrator's determinations, the Supreme Court has held that where a benefits plan gives the "administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan," then a court should review the plan administrator's decision only for abuse of discretion. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 956-57, 103 L.Ed.2d 80 (1989); see also Cox v. Mid-America Dairymen, Inc., 965 F.2d 569, 571 (8th Cir.1992), aff'd after remand, 13 F.3d 272 (8th Cir.1993). Because it is undisputed that the benefits plan at issue grants discretionary interpretive authority to the plan trustees, ⁵ we review the benefits determination for abuse of discretion.

Buttram offers two arguments in support of overturning the plan administrator's determination. First, he contends that a "less deferential" abuse of discretion standard should be applied because of the presence of procedural irregularities in this case. Second, he argues that the substantive decision denying benefits was an abuse of discretion. We address each argument in turn.

A.

In certain situations, factors external to the actual decision on the merits can mandate the application of a less deferential abuse of discretion standard. Under the common law of trusts, which is our guide in reviewing the benefits determinations of ERISA plan trustees, see Bruch, 489 U.S. at 110-11, 109 S.Ct. at 954-55, where the plan trustee labors under a conflict of interest, see Restatement (Second) of Trusts § 187 cmt. d (1959), or where, in the exercise of his power, he acts dishonestly, see id. cmt. f, or from an improper motive, see id. cmt. g, or he fails to use judgment in reaching his decision, see id. cmt. h, the resulting decision may be accorded stricter scrutiny. ⁶

For this heightened review to apply, the beneficiary must show (1) that a serious procedural irregularity existed, which (2) caused a serious breach of the plan trustee's fiduciary duty to the plan beneficiary. See Atwood v. Newmont Gold Co., Inc., 45 F.3d 1317, 1323 (9th Cir.1995). However, absent material, probative evidence, beyond the mere fact of the apparent irregularity, tending to show that the administrator breached his fiduciary obligation, see id. (requiring plaintiff to come forward with specific evidence of conflict of interest); see also Cuddington v. Northern Ind. Pub. Serv. Co., 33 F.3d 813, 816 (7th Cir.1994) (same), we will apply the traditional abuse of discretion analysis to discretionary trustee decisions.

Buttram notes that he never received written notice in 1988 when his benefits claim was denied, he never received his second-level appeal, and his third-level appeal took place seven years after his application for benefits; we interpret these claims as alleging that the plan trustees failed to use their judgment in rendering the decision or that their decision was arbitrary or made on a whim. ⁷ Buttram further notes that his third-level appeal occurred only after suit had been filed and after the trustees had moved for summary judgment, on the grounds that Buttram was not entitled to benefits. Buttram contends that the plan trustees therefore acted under a conflict of interest and that the outcome was a foregone conclusion. Neither of these contentions has merit.

Buttram did not come forward with any evidence establishing that the plan trustees failed to use judgment in rendering their decision. We note first that Buttram could have satisfied this burden by providing material, probative circumstantial evidence that left the court with serious doubts as to whether the result reached was the product of an arbitrary decision or the plan administrator's whim; see Restatement (Second) of Trusts § 187 cmt. h. For example, where the plan trustee does not inquire into the relevant circumstances at issue; where the trustee never offers a written decision, so that the applicant and the court cannot properly...