Pritt v. UMWA 1950 BEN. PLAN AND TRUST

• Decision Date: 28 March 1994
• Docket Number: No. 2:93-0473.,2:93-0473.
• Citation: 847 F. Supp. 427
• Court: U.S. District Court — Southern District of West Virginia
• Parties: Davis J. PRITT, Individually and Davis J. Pritt, as Administrator of the Estate of Virgie E. Pritt, Plaintiff, v. UNITED MINE WORKERS OF AMERICA 1950 BENEFIT PLAN AND TRUST, United Mine Workers of America 1974 Benefit Plan and Trust, Paul R. Dean, Michael H. Holland, Marty D. Hudson, Elliot A. Segal, Trustees, Defendants.

847 F. Supp. 427

Davis J. PRITT, Individually and Davis J. Pritt, as Administrator of the Estate of Virgie E. Pritt, Plaintiff, v. UNITED MINE WORKERS OF AMERICA 1950 BENEFIT PLAN AND TRUST, United Mine Workers of America 1974 Benefit Plan and Trust, Paul R. Dean, Michael H. Holland, Marty D. Hudson, Elliot A. Segal, Trustees, Defendants.

No. 2:93-0473.

United States District Court, S.D. West Virginia, Charleston Division.

March 28, 1994.

H. John Taylor, Rand, WV, for plaintiff.

Margaret M. Topps and Susan Kornetsky, UMWA Health & Retirement Funds, Washington, DC, Mary Jane Pickens and Susan Cannon-Ryan, Caldwell, Cannon-Ryan & Riffee, Charleston, WV, for defendant.

MEMORANDUM OPINION AND ORDER

HADEN, Chief Judge.

Pending are the cross-motions of the parties for summary judgment. Both parties assert there are no issues of material fact in dispute and that they are entitled to judgment as a matter of law.¹

I.

The Plaintiff seeks payment of certain medical expenses for skilled nursing care incurred during the course of the treatment of his late wife (the decedent). The decedent was a covered beneficiary under a benefit Plan operated by the Defendants. The decedent came under the care of the Summersville Memorial Hospital Extended Care Unit in May of 1989. Apparently, she remained there through 1993. Although portions of decedent's treatment were covered by Medicare, substantial portions were not. The Plan agreed to cover part of the skilled nursing care not covered by Medicare, but not all of it.²

Plaintiff contends the Plan's coverage of some of the skilled nursing care expenses is inconsistent with its denial of benefits for the other portion of skilled nursing care expenses. The Plan argues it granted benefits for skilled nursing care only where such care was medically necessary, and that during the months benefits were denied, the skilled nursing care was not "medically necessary." Plaintiff contends the benefits denied by the Plan for skilled nursing care were identical to benefits approved for skilled nursing care, and that denial of benefits in that situation constitutes an abuse of discretion by the Plan.

II.

The standard of review of a decision made by Trustees of an ERISA benefit plan is ordinarily de novo. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 956, 103 L.Ed.2d 80 (1989); Richards v. United Mine Workers of America Health and Retirement Fund, 895 F.2d 133, 135 (4th Cir.1990); de Nobel v. Vitro Corp., 885 F.2d 1180, 1186 (4th Cir.1989). However, where the Plan gives the Trustees discretion to determine benefit eligibility or to construe plan terms, the standard of review is whether the Trustees abused that discretion.³ Firestone, supra, 489 U.S. at 111, 109 S.Ct. at 954, 103 L.Ed.2d at 92-93 ("Trust principles make a deferential standard of review appropriate when a trustee exercises discretionary powers. Where discretion is conferred upon the trustee with respect to the exercise of a power, its exercise is not subject to control by the court except to prevent an abuse of discretion. A trustee may be given power to construe disputed or doubtful terms, and in such circumstances the trustee's interpretation will not be disturbed if reasonable." (citations and internal quotations omitted)). The parties agree that the appropriate standard of review in this case is whether the trustees committed an abuse of their discretion.⁴

The Court of Appeals discussed the criteria used to determine whether an abuse of discretion had been made by Trustees of a benefit plan in Lockhart v. United Mine Workers of America 1974 Pension Trust, 5 F.3d 74, 77 (4th Cir.1993):

"In determining whether the trustees of an employment benefits plan abused their discretion in denying benefits,

we must give due consideration, for example, to whether administrators' interpretation is consistent with the goals of the plan; whether it might render some language in the plan meaningless or internally inconsistent; whether the challenged interpretation is at odds with the procedural and substantive requirements of ERISA itself; whether the provisions at issue have been applied consistently; and of course whether the fiduciaries' interpretation is contrary to the clear language of the plan.

The dispositive principle remains, however, that where plan fiduciaries have offered a reasonable interpretation of disputed provisions, courts may not replace it with an interpretation of their own.

de Nobel v. Vitro Corp., 885 F.2d 1180, 1188 (4th Cir.1989) (internal citations and quotation marks omitted)."

III.

Applying the factors outlined in Lockhart, supra, at 78, and de Nobel, supra, "the award of benefits under any ERISA plan is governed in the first instance by the language of the plan itself. If the denial of benefits is contrary to the clear language of the plan, the decision will constitute an abuse of discretion." (citations and internal quotation marks omitted).⁵ The plan provisions at issue allow "skilled nursing care provided by or under the supervision of a registered nurse," when such care is "medically necessary," but specifically excludes such care when it constitutes mere "custodial care."⁶

Our Court of Appeals was faced with a similar scenario in O'Connor v. Central Virginia U.F.C.W., 945 F.2d 799, 802 (4th Cir. 1991). The dispute therein arose over whether certain nursing care services were medically necessary or custodial in nature. Although the Plan therein, like the instant Plan, did not define "custodial care," the Court accepted the following definition: "Services focusing on supporting the patient in activities of daily living (ADL's), observation, supervision and evaluation for regression and complications."⁷See, e.g., Dvorak v. Metropolitan Life Ins. Co., 965 F.2d 606, 610 (8th Cir.1992) (accepting definition of "principally custodial care" as, "the attention given to the safety and well-being of the individual that most importantly or consequently consists of protection, care, maintenance, and tuition."); Barnett v. Weinberger, 818 F.2d 953, 968 (D.C.Cir.1987) ("Courts almost uniformly have interpreted as descriptive of custodial care that which `can be provided by a lay person without special skills and not requiring or entailing the continued attention of trained or skilled personnel,'" interpreting the Medicare statute, Title XVIII of the Social Security Act (42 U.S.C. § 1395-1395ccc) and quoting Kuebler v. Secretary of United States Dep't of Health & Human Services, 579 F.Supp. 1436, 1438 (E.D.N.Y.1984) and citing Hayner v. Weinberger, 382 F.Supp. 762, 766 (E.D.N.Y.1974)); Camelot Care Centers, Inc. v. Planters Lifesavers Co., 836 F.Supp. 545, 549-51 (N.D.Ill. 1993); Adelson v. GTE Corp., 790 F.Supp. 1265, 1271 (D.Md.1992) ("Custodial care is not defined in the Plan documents and it appears to have a common sense meaning: the providing of assistance by a lay person without special skills in such matters as eating, clothing, washing and toileting." Citing O'Connor, supra; Coe v. Secretary of Health, Ed., and Welfare, 502 F.2d 1337 (4th Cir. 1974); Hirsch v. Bowen, 655 F.Supp. 342 (S.D.N.Y.1987)); Erickson v. Aetna Life Ins. Co., 777 F.Supp. 1463, 1467 (D.Minn.1991) (accepting definition of custodial care as defined by that plan: "care that is provided primarily to assist the individual in the activities of daily living. * * * Those activities include eating, dressing, grooming, voiding, and moving the extremities to maintain muscle condition.").

The O'Connor Court went on to analyze the dispute therein as follows:

"The question is whether Mrs. O'Connor's needs are properly characterized as medical or custodial. While we may be illequipped to determine the precise nature of particular services, the basic parameters seem clear. * * * Covered medical services apparently include the services of a nurse in monitoring Mrs. O'Connor's blood pressure and seizure activity. There is little dispute ... that Mrs. O'Connor needs at least intermittent skilled medical care which the trustees are plainly obligated to provide.

"On the other hand the services of a companion or attendant in helping with activities of daily living (e.g., feeding, clothing, bathing) can legitimately be considered to fall outside the covered medical charges. Deference must be accorded the determinations of the trustees with respect to the nature and level of care required so long as those determinations are supported by substantial medical evidence rendered by qualified medical personnel. See Boyd v. Trustees of United Mine Workers Health & Retirement Fund, 873 F.2d 57, 59-60 (4th Cir.1989) (determination which was supported by substantial evidence `lay within the trustees discretion'); Lefebre v. Westinghouse Elec. Corp., 747 F.2d 197, 204 (4th Cir.1984).... Where `there is a mix of custodial and noncustodial services performed by home care' personnel, `the fiduciary remains obligated to honor those portions of claims that represent noncustodial home nursing care and are medically prescribed.' Cathey v. Dow Chemical Co. Medical Care Program, 907 F.2d 554, 561 (5th Cir.1990)." 945 F.2d at 802. (emphasis in original).

In this case the decedent's treating physician made monthly reports to the Plan in which she asserted the decedent required "skilled nursing care" for a variety of reasons. The treating physician stated, "decedent requires skilled nursing care due to daily G-tube feedings to maintain adequate fluid and daily nutritional levels. Her diabetes requires close monitoring." Defendant's exhibit A at 307.⁸ The treating physician also made the following observation in a letter dated August 8, 1991:

"Basically Mrs. Pritt requires total care. She has a gastrostomy feeding tube which is checked on a daily basis as well as changed by the registered nurse or myself every thirty days. In the past Mrs. Pritt has had some trouble with her tube wanting to pull into her abdomen and at times has even required

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