Hampton v. District Council 37 Health & Sec. Plan

• Decision Date: 31 October 1978
• Citation: 411 N.Y.S.2d 124,97 Misc.2d 324
• Court: New York City Court
• Parties: Leah HAMPTON, Plaintiff, v. DISTRICT COUNCIL 37 HEALTH & SECURITY PLAN, Defendant.

Page 124

411 N.Y.S.2d 124

97 Misc.2d 324

Leah HAMPTON, Plaintiff, v. DISTRICT COUNCIL 37 HEALTH & SECURITY PLAN, Defendant.

Civil Court of City of New York, Kings County.

Oct. 31, 1978.

Leah Hampton, pro se.

Hartman & Craven by Gary H. Shapiro, New York City, for defendant.

DECISION

ANNE G. FELDMAN, Judge.

Judgment for plaintiff in the amount of $1,000 without interest.

This is an action to recover from a union benefits plan (hereinafter "the Plan") for dental bridgework in the amount of $2,000. Plaintiff, a member of defendant D.C. 37, required immediate dental services and consulted Dr. Gerald Stern who examined plaintiff in September, 1977 and submitted to defendant a "statement of precertification" setting forth a proposed course of treatment including extractions, root canals, crowns and a bridge. All but $74 of this "statement of precertification" was rejected by Defendant's Group Claim Division, through its carrier Prudential Insurance Company, because plaintiff had received benefits on August, 1975 for a partial denture and, under the rules of the Plan, was ineligible for benefits covering "Replacement of a prosthetic device where that device was originally inserted within the immediately preceding five (5) calendar years Either in whole or in part." (D.C.Health & Security Plan, p. 29) (emphasis added). Plaintiff protested this decision, pointing out that she was in extreme pain, that she had to have three front teeth extracted, and that her 1975 bridge for two back teeth was useless to her under the circumstances. Plaintiff even sent $200 to Prudential to reimburse the Plan for what it paid the dentist who made the bridge in 1975. Prudential returned her check with the explanation that the denial of liability for the replacement of prosthetic devices is "contractual" and governed by "provisions as outlined in the group contract."

Plaintiff then proceeded with the necessary dental work on the advice of Dr. Stern, who noted in his precertification statement that in his opinion it was essential to do the work quickly to avoid aggravating her condition. After the work was completed, plaintiff submitted a claim on which no official action has yet been taken in accordance with defendant's policy of delaying the processing of claims while litigation is pending. However, defendant does not deny that this claim, which at the time of trial had been pending six months, will be officially rejected on the same basis as was the precertification statement.

Plaintiff, a dues paying member of D.C. 37, was a third party beneficiary to the contract between defendant and Prudential Insurance Company and as such may enforce defendant's duty to provide coverage to her as a member. (Lawrence v. Fox, 20 N.Y. 268 (1859)).

The threshold question is whether this is an equitable action in which this Court lacks jurisdiction. Defendant's Plan, under which plaintiff seeks benefits, is a trust, the assets of which are administered by its trustees, (ERISA, 29 U.S.C. §§ 1001-114). The nature of an action to declare and enforce rights in a trust fund has been held to sound in equity (see, e. g., Hellman v. Ploss, 46 A.D.2d 658, 359 N.Y.S.2d 823 (2d Dept. 1974); Sommers v. Horsford, N.Y.L.J., Feb. 13, 1976, p. 10, col. 3 (S.Ct., Bronx Co.). Defendant argues that this is a case involving rights under a trust which should, under the New York Constitution, art. 6, sec. 19(f), be transferred to a court with equitable jurisdiction.

However, defendant's argument fails to meet the real issues in this case. While the trustees of the Plan have the fiduciary power to manage its assets, there is no showing that they exercise fiduciary discretion in executing the contractual provisions of the Plan. Rather, it appears that the trustees contracted with Prudential Insurance Company to provide dental coverage for members and, as the documentary evidence indicates, it is Prudential which interprets the contract as it applies to members of D.C. 37.

This Court does not have before it for review an exercise of fiduciary discretion. Rather, to decide this case the Court is called upon to construe the contract between the Plan and its insurer, a matter clearly "cognizable in a court of law." (Society of N. Y. Hospital v. Malsky, 86 Misc.2d 221, 223, 382 N.Y.S.2d 433, 435 (Civil Ct., N.Y.Co.), Aff'd, 88 Misc.2d 832, 390 N.Y.S.2d 512 (App.T., 1st Dept. 1976)).

Based upon the credible evidence before it, this Court finds the contractual construction urged by defendant to be unwarranted. The dental bridgework installed by Dr. Stern involved eleven teeth. This was so different from the work done in 1975 which involved replacing only two teeth that it cannot be construed as a "replacement" of the device installed then. ¹ Moreover, defendant failed to produce any evidence to support its claim that it has a consistent policy of denying benefits for bridgework where any bridgework in a remotely contiguous area of the mouth has been done in the...