Camelot Care Centers v. Planters Lifesavers Co.

• Decision Date: 02 November 1993
• Docket Number: No. 92 C 1671.,92 C 1671.
• Citation: 836 F. Supp. 545
• Parties: CAMELOT CARE CENTERS, INC., Plaintiff, v. PLANTERS LIFESAVERS COMPANY, et al., Defendants.
• Court: U.S. District Court — Northern District of Illinois

836 F. Supp. 545

CAMELOT CARE CENTERS, INC., Plaintiff, v. PLANTERS LIFESAVERS COMPANY, et al., Defendants.

No. 92 C 1671.

United States District Court, N.D. Illinois, E.D.

November 2, 1993.

Tobin Richter, for plaintiff.

Stephen M. Naughton, for Nestle.

David Americus, for Planters.

MEMORANDUM OPINION AND ORDER

SHADUR, Senior District Judge.

Camelot Care Centers, Inc. ("Camelot") has sued Planters Lifesavers Company ("Planters"), Nabisco Brands, Inc. Hourly Employee Benefit Plan ("Plan") and Nestle Food Company, Inc. ("Nestle"), as assignee of benefits due to a Planters employee under the Plan. Planters and Plan have now filed a joint motion for summary judgment, Camelot has responded with a summary judgment motion of its own, and Nabisco has joined in its codefendants' motion and in their resistance to Camelot's motion. For the reasons stated in this memorandum opinion and order, Camelot's motion is granted and all defendants' motions are denied.

Summary Judgment Principles

Familiar Rule 56 principles impose on the movant the burden of establishing the lack of a genuine issue of material fact (Celotex Corp. v. Catrett, 477 U.S. 317, 322-23, 106 S.Ct. 2548, 2552-53, 91 L.Ed.2d 265 (1986)). For that purpose this Court is "not required to draw every conceivable inference from the record — only those inferences that are reasonable" — in the light most favorable to the nonmovant (Bank Leumi Le-Israel, B.M. v. Lee, 928 F.2d 232, 236 (7th Cir.1991) and cases cited there). Where as here cross-motions are involved, that principle thus demands a dual perspective — one that this Court has often described as Janus-like — that sometimes involves the denial of both motions.

As the later discussion will indicate, the need for such a dual perspective does preclude a summary judgment in either direction on certain of the grounds placed at issue by the parties, because there are indeed material fact issues in dispute relevant to those grounds. That not only obviates the need to set out the disputed facts bearing on those grounds, but it also renders unnecessary this Court's entry into any analysis of the not-always-consistent Seventh Circuit decisions in the area. Accordingly what follows in the next section is limited to a statement of the facts that are relevant to the self-contained issue on which Camelot unquestionably prevails.

Facts

When this dispute was triggered in early 1990, M.R.¹ worked for Planters, a division of Nabisco Brands, Inc. ("Nabisco") that maintained a facility in Franklin Park, Illinois. M.R. was covered by the Plan, an employee health benefit plan administered for Nabisco by Prudential Insurance Company of America ("Prudential"). Nabisco had issued a Summary Plan Description ("SPD") effective September 1, 1987 to outline the terms and conditions of the Plan. That SPD remained in effect throughout the relevant time period.

In February 1990 M.R.'s daughter C.R., who was a covered dependent under the terms of the Plan, began suffering from major depression, borderline personality disorder and socialized nonaggressive conduct disorder. After a diagnosis by Camelot's Medical Director Dr. Albert Lang, C.R. was admitted by Camelot on February 12, 1990. On that same day M.R. assigned to Camelot all rights to employee benefits afforded by the Plan.

On February 23, 1990 Nabisco sold the assets of the Franklin Park facility to Nestle. All the terms of the Plan remained in effect, but Nestle replaced Prudential as Plan administrator with its own insurer, Aetna Insurance ("Aetna"). Shortly after the sale to Nestle and the change in Plan administrators, Prudential paid an amount under the Plan attributable to the first four days of C.R.'s stay at Camelot (a period that had preceded the sale and changeover). Meanwhile C.R. had been receiving continuous therapy, and Camelot asked the Plan to continue to cover those costs. That request was denied on the stated grounds that Camelot is not a "hospital" as defined by the Plan because it assertedly furnishes "primarily custodial or domiciliary care" — an express exclusion from the Plan's definition of "hospital."

It is undisputed that the Plan includes, within its major medical expense benefit coverage, "Hospital Room and Board" and "Other Hospital Services" (Plan at 10-11). Plan at 13 goes on to state:

MENTAL, PSYCHONEUROTIC AND PERSONALITY DISORDERS

In the case of mental, psychoneurotic and personality disorders, the Plan covers services received during a hospital confinement resulting in a room and board charge.

As one of the exclusions from its major medical expense coverage, Plan at 15 lists:

6. Services received in connection with a mental, psychoneurotic or personality disorder while not confined in a hospital.

Finally, in its section setting out "DEFINITIONS FOR THE PURPOSE OF THE PLAN," Plan at 21 reads:

Hospital — A legally operated institution which meets either of these tests:

1. Is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on the Accreditation of Hospitals, or

2. Is supervised by a staff of doctors, has 24-hour-a-day nursing service and is primarily engaged in providing either:

a. General inpatient medical care and treatment through medical, diagnostic and major surgical facilities on its premises or under its control, or

b. Specialized inpatient medical care and treatment through medical and diagnostic facilities (including X-ray and laboratory) on its premises, or under its control, or through a written agreement with a hospital (which itself qualifies under 1 or 2 of this definition) or with a specialized provider of these facilities.

In no event will the term "hospital" include a nursing home or an institution or part of one which (a) is primarily a facility for convalescence, nursing, rest, or the aged, or (b) furnishes primarily domiciliary or custodial care, including training in daily living routines, or (c) is operated primarily as a school.

Camelot states, and none of the defendants disputes, that no copy of the Plan itself was furnished to M.R. as a participant. Instead, as is typical in connection with employee benefit plans provided by large employers, she was given an SPD booklet. Here are the relevant portions of the SPD (at pages 4 and 8-9 (boldface type in original)):

Basic Hospital Expense Benefit

Hospital Room and Board, If you or a covered dependent requires hospitalization, coverage for up to 120 days is provided for the cost of semi-private room, meals and general nursing service.

* * * * * *

Mental Illness

If you or your dependents incur covered medical expenses while confined in a hospital for mental illness or functional nervous disorder, the same benefits will be payable as provided for any other disability.

No benefits will be paid for mental illness or functional nervous disorder when not confined to a hospital.

Expenses Not Covered

Medical expenses that are not covered include:

* * * * * *

• charges for custodial care.

Though the Plan sets out the earlier-quoted definition of "hospital," no definition of that term is included in the SPD. And neither the Plan nor the SPD attempts to define the phrase "primarily custodial or domiciliary care" that is included in the Plan's definition of "hospital." Camelot's facilities, and the parties' respective contentions as to how they fit or do not fit within the Plan's coverage, will be discussed in the section of this opinion dealing with the legal issues involved.

After Camelot's principal claim for payment had been rejected, it brought suit (pursuant to the assignment of M.R.'s rights) against Planters, the Plan and Nestle. It seeks $93,154.90 for unreimbursed medical treatment furnished to C.R., plus prejudgment interest and attorneys' fees. Although the parties have formed battle lines on other fronts as well, this case proves to be capable of disposition on the ground that Camelot is indeed a "hospital" for Plan purposes, so that the denial of coverage is actionable under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1001-1145.² That issue will be dealt with first, to be followed by a very brief discussion of other matters.

Camelot As a "Hospital"

Although Camelot is clearly not the conventional self-contained type of hospital that can seek and obtain accreditation as such (alternative 1 in the Plan's definition of the term),³ Camelot demonstrates — and defendants do not controvert — that it meets the requirements of alternative 2.b except for one disputed fact. It is "supervised by a staff of doctors," it does have "24-hour-a-day nursing service" and it is "engaged in providing ... specialized inpatient medical care and treatment through medical and diagnostic facilities (including X-ray and laboratory)" — some of those "on its premises" and the others "through written agreements with hospitals ... or with specialized providers of those services." Nor do defendants quarrel with Camelot's clear showing that it is not a nursing home.

Where the parties do part company is over the issue whether the just-referred-to "medical care and treatment" represent Camelot's primary activity, as definition 2.b requires. Instead defendants' opening gun⁴ contended (1) that Camelot is not a "hospital" as defined in the Plan because it "furnishes primarily domiciliary or custodial care" and (2) that Camelot cannot invoke the other theories advanced in its Complaint to permit it to recover in this action. Camelot has met the argument as to the meaning of the Plan head-on, as well as attempting some glancing blows to attack the denial of benefits by the Plan.

Because the dispositive claim is one under Section 1132(a)(1)(B) — an action to enforce rights or recover benefits due under the terms of the Plan — a word should first be said as to the appropriate standard of review of the Plan administrator's refusal to pay. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 108-15, 109 S.Ct. 948, 953-56, 103...