Alves v. Silverado Foods, Inc. ( 2001 )

F I L E D
United States Court of Appeals
Tenth Circuit
UNITED STATES COURT OF APPEALS
MAR 9 2001
TENTH CIRCUIT
PATRICK FISHER
Clerk
___________________________
JOSEPH E. ALVES AND
KRISTI ALVES,
Plaintiffs-Appellants,
No. 00-5011
v. (D.C. No. 99-CV-48-K)
(N.D. Okla.)
SILVERADO FOODS, INC. AND
SILVERADO FOODS WELFARE
BENEFIT PLAN,
Defendants-Appellees.
___________________________
ORDER AND JUDGMENT *
___________________________
Before SEYMOUR, Circuit Judge, McWILLIAMS, Senior Circuit Judge, and
BELOT, District Judge. **
___________________________
* This order and judgment is not binding precedent, except under the doctrines of
law of the case, res judicata, and collateral estoppel. The court generally disfavors the
citation of orders and judgments; nevertheless, an order and judgment may be cited under
the terms and conditions of 10th Cir. R. 36.3.
**
Monti L. Belot, United States District Judge for the District of Kansas, sitting by
designation.
After examining the briefs and appellate record, this panel has determined
unanimously to honor the parties’ request for a decision on the briefs without oral
argument. See Fed. R. App. P. 34(f). The case is therefore submitted without
oral argument.
INTRODUCTION
Joseph and Kristi Alves appeal the district court’s final order and judgment
granting in part and denying in part their motion for summary judgment The
Alves filed this ERISA enforcement action seeking declaratory and injunctive
relief after their employee welfare benefit plan refused to pay medical benefits.
On cross-motions for summary judgment, the district court found the plan’s
refusal justified due to the Alves’ refusal to sign a reimbursement
acknowledgment form. We exercise jurisdiction under 28 U.S.C. § 1291 and
affirm.
BACKGROUND
Through his employer, Silverado Foods, Inc., Joseph Alves participated in
the Silverado Foods Welfare Benefit Plan (“the Plan”), an “employee welfare
benefit plan” governed by the Employee Retirement Income Security Act of 1974,
29 U.S.C. § 1001, et. seq. (“ERISA”). Alves’ wife and minor son, Kristi and
Braden Alves, were beneficiaries of the Plan and were thus “covered persons”
under the terms of the Plan. Silverado Foods, Inc. is the Named Fiduciary of the
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Plan.
Pursuant to 29 U.S.C. § 1021(a), the Plan distributed a Summary Plan
Description (“SPD”) to its plan participants and beneficiaries. 1 Importantly, for
purposes of this litigation, the SPD provided for the Plan’s subrogation rights in
instances of third-party recovery situations. The SPD stated:
RIGHT OF SUBROGATION AND REFUND
When this provision applies. The Covered Person may incur
medical or dental charges due to injuries which may be caused by the
act or omission of a third party. In such circumstances, the Covered
Person may have a claim against that third party, or insurer, for
payment of the medical or dental charges. Accepting benefits under
this Plan for those incurred medical or dental expenses automatically
assigns to the Plan any rights the Covered Person may have to
recover payments from any third party or insurer. This subrogation
right allows the Plan to pursue any claim which the Covered Person
has against any third party, or insurer, whether or not the Covered
Person chooses to pursue that claim. The Plan may make a claim
directly against the third party or insurer, but in any event, the Plan
has a lien on any amount recovered by the Covered Person whether
or not designated as payment for medical expenses. This lien shall
remain in effect until the Plan is repaid in full.
The Covered Person:
C automatically assigns to the Plan his or her rights against
any third party or insurer when this provision applies;
and
1
ERISA requires an SPD to be “written in a manner calculated to be understood
by the average plan participant, and . . . be sufficiently accurate and comprehensive to
reasonably apprise such participants and beneficiaries of their rights and obligations
under the plan.” 29 U.S.C. § 1022(a)(1); see also 29 C.F.R. § 2520.102-2(a) and (b).
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C must repay to the Plan the benefits paid on his or her
behalf out of the recovery made from the third party or
insurer.
Amount subject to subrogation or refund. The Covered Person
agrees to recognize the Plan’s right to subrogation and
reimbursement. These rights provide the Plan with a priority over
any funds paid by a third party to a Covered Person relative to the
Injury or Sickness, including a priority over any claim for non-
medical or dental charges, attorney fees, or other costs and expenses.
Notwithstanding its priority to funds, the Plan’s subrogation and
refund rights, as well as the rights assigned to it, are limited to the
extent to which the Plan has made, or will make, payments for
medical or dental charges as well as any costs and fees associated
with the enforcement of its rights under the Plan.
When a right or recovery exists, the Covered Person will execute and
deliver all required instruments and papers as well as doing whatever
else is needed to secure the Plan’s right of subrogation as a condition
to having the Plan make payments. In addition, the Covered Person
will do nothing to prejudice the right of the Plan to subrogate.
Defined terms: “Recovery” means monies paid to the Covered
Person by way of judgment, settlement, or otherwise to compensate
for all losses caused by the Injuries or Sickness whether or not said
losses reflect medical or dental charges covered by the Plan.
“Subrogation” means the Plan’s right to pursue the Covered Person’s
claims for medical or dental charges against the other person.
“Refund” means repayment to the Plan for medical or dental benefits
that it has paid toward care and treatment of the Injury or Sickness.
(Summary Plan Description at 34; Aplt. App., Tab 7 at 000194).
On March 3, 1997, Kristi and Braden Alves were involved in a catastrophic
motor vehicle accident in which Kristi Alves suffered a permanent and
irreversible brain injury. As a result of the injuries sustained from the accident,
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the Alves incurred medical expenses totaling $ 103,514.24. The Alves filed suit
in Texas against the tortfeasor who tendered the limits of an available liability
policy in the amount of $ 100,000. The Texas state court action has not been
resolved, nor have the Alves accepted the $ 100,000 tendered.
The Alves submitted their medical bills to the Plan for processing and
payment. The Plan, however, required the Alves to sign a standard
reimbursement acknowledgment form before it would pay out any benefits. The
acknowledgment form read:
In accordance with the Subrogation provision of the SILVERADO
FOODS Employee Health Benefit Plan, the undersigned hereby
agrees to reimburse and pay promptly to the SILVERADO FOODS
Employee Health Benefit Plan an amount not exceeding the
aggregate amount of benefits paid or to be paid to me or on my
behalf under said Plan for charges incurred as a result of injury
sustained or disease contracted on or about ______________ in
_________ County, State of ________________ out of recovery by
settlement or judgment or otherwise, from any person’s or
organization’s insurance.
The undersigned agrees to execute instruments and papers, furnish
information and assistance, and to take other necessary and related
actions that SILVERADO FOODS may require to facilitate its right
of reimbursement under the Employee Health Benefit Plan.
The undersigned represents and warrants that no release or discharge
has been given with respect to his (their) rights of recovery described
herein and that the undersigned has done nothing to prejudice said
rights.
The Alves refused to sign the acknowledgment form, believing the form granted
the Plan additional rights and that their signing the form would waive their legal
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rights.
The Plan then offered the Alves a second “supplemental” reimbursement
acknowledgment form as an alternative to the first acknowledgment form. As
with the first reimbursement acknowledgment form and for the same reasons, the
Alves refused to sign the supplemental acknowledgment form. Because the
Alves refused to sign either of the reimbursement acknowledgment forms, the
Plan refused to pay their claims for medical expenses.
The Alves filed this ERISA action against the Plan seeking declaratory and
injunctive relief. The Alves asked the district court to require the Plan to process
and pay the benefits due under the terms of the plan. The Alves also asked the
district court to clarify the impact of the subrogation language contained in the
plan. The Alves further sought damages for the Plan’s breach of its fiduciary
duties. The Plan responded with a counterclaim for declaratory relief. The Plan
asked the district court to determine that not only did it have the right to refuse to
pay the Alves’ medical bills until after the Alves signed the reimbursement
acknowledgment form, but that it would also have a priority over any recoveries
the Alves would receive from third parties as reimbursement for its payment of
the Alves’ medical bills.
In their motion for summary judgment, the Alves contended the Plan would
not have a priority over the expected settlement with the tortfeasor’s insurer
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because, as their actual medical expenses exceeded the expected recovery, they
would not be made whole. The Alves further alleged the Plan breached its
fiduciary duties to them in three ways: by refusing to process and pay the claims,
by proposing the supplemental reimbursement agreements, and by attempting to
hire the Alves’ attorney to represent the Plan’s interests in the case against the
third-party tortfeasor. The Plan also moved for summary judgment, arguing the
subrogation clause was not void as a matter of law, the SPD specifically provides
the Plan with the right to require a reimbursement acknowledgment form prior to
its paying benefits, and that the Alves’ refusal to sign such forms breached their
duty under the terms of the SPD, justifying the Plan’s refusal to pay medical
benefits.
THE DISTRICT COURT OPINION
After concluding that an “arbitrary and capricious” standard of review was
applicable, the district court first determined the Plan’s subrogation rights would
not vest until after the plan paid benefits. Because the Plan had, as of the time of
the opinion, failed to pay benefits, the Plan had no subrogation rights. However,
the real question, the district court determined, was whether the Plan could
require a signed subrogation form before paying benefits. The district court
answered that it was reasonable for the Plan to require a signed document
securing the Plan’s right of subrogation (even before that right of subrogation
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exists) prior to paying benefits.
The district court determined it was reasonable for the Plan to require the
Alves to sign the first offered subrogation form because the form was a
reasonable restatement of the SPD’s subrogation provision. The district court
found the second offered subrogation form to contain several misrepresentations
and unreasonable interpretations of the plan. After noting that the Plan only
required plaintiffs to sign one of the subrogation forms, the court found it not
arbitrary and capricious to require signing of the first, but that it was arbitrary and
capricious to require a signing of the second.
Next, the district court discussed the application of the Make Whole
doctrine. After discussing the circuit split and the Tenth Circuit’s lack of
opportunity thus far to decide the issue, the district court found it did not need to
determine whether ERISA plans are subject to the Make Whole doctrine because
the Plan’s subrogation provision was an explicit contractual rejection of the
doctrine. The district court quoted the SPD as stating that the Plan’s subrogation
and reimbursement rights
provide the Plan with a priority over any funds paid by a third party
to a Covered Person relative to the Injury or Sickness, including a
priority over any claim for non-medical or dental charges, attorney
fees, or other costs and expenses. Notwithstanding its priority to
funds, the Plan’s subrogation and refund rights . . . are limited to the
extent to which the Plan has made, or will make, payments for
medical or dental charges as well as any costs and fees associated
with the enforcement of its rights under the Plan.
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Dist. Ct. Op. at 13 (quoting Summary Plan Description at 34) (emphasis added).
To this the district court explained that the provision “explicitly adopt[ed] the
Plan Priority rule, the opposite of [M]ake [W]hole, whereby the Plan must be
completely reimbursed before [the Alves] can keep any of the money recovered
from the third-party tortfeasor.” Dist. Ct. Op. at 13.
As for the Alves’ claims that the Plan breached its fiduciary duty, the
district court first determined the plan did not as to its (1) refusal to pay benefits;
and (2) requiring the signing of the first subrogation agreement before paying
benefits because the court had previously determined neither action was based on
an unreasonable reading the plan. The district court found the Plan properly
interpreted the Plan’s provision regarding subrogation, and thus, it did not breach
its ERISA-imposed fiduciary duty.
Although the district court acknowledged the second offered subrogation
form was contrary to the SPD’s language, the court found the error harmless
because the Alves could have signed the first subrogation agreement offered to
them. As for the breach of fiduciary duty claim based on the Plan’s attempt to
hire the Alves’ attorney, the district court pointed out that the “offer” of hiring
the Alves’ attorney came from Johnson Brokers and Administrators, not the Plan.
Johnson Brokers was hired by the Plan to administer claims submitted to the Plan.
The Alves did not present any evidence attributing the offer from the Plan itself.
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The Alves now appeal the district court’s holdings that the Plan’s
subrogation and refund rights are not subject to the Make Whole rule and that the
Plan did not breach its fiduciary duties to the Alves.
STANDARD OF REVIEW
Review of a grant of summary judgment is de novo, applying the same legal
standard used by the district court. See Charter Canyon Treatment Ctr. v. Pool
Co., 153 F.3d 1132, 1135 (10 th Cir. 1998). A district court’s review of a
beneficiary’s challenge to a denial of benefits under 29 U.S.C. § 1132(a)(1)(B)
applies an “arbitrary and capricious” standard to a plan administrator’s actions if
the plan grants the administrator discretionary authority to determine eligibility
for benefits or to construe the plan’s terms. See Kimber v. Thiokol Corp., 196
F.3d 1092, 1097 (10 th Cir. 1999) (citing Firestone Tire & Rubber Co. v. Bruch,
489 U.S. 101, 115, 109 S.Ct. 948, 956-57, 103 L.Ed.2d 80 (1989)). In this case,
the district court determined the Plan’s SPD did grant the administrator such
discretionary authority and applied the arbitrary and capricious standard. On
appeal, the Alves do not challenge this determination.
When reviewing under the arbitrary and capricious standard, “[t]he
Administrator[’s] decision need not be the only logical one nor even the best one.
It need only be sufficiently supported by facts within [its] knowledge to counter a
claim that it was arbitrary and capricious. . . . The decision will be upheld unless
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it is not grounded on any reasonable basis. The reviewing court need only assure
that the administrator’s decision fall[s] somewhere on a continuum of
reasonableness–even if on the low end.” Id. at 1098 (internal citations and
quotations omitted).
THE MAKE WHOLE DOCTRINE
ERISA itself is silent with respect to subrogation and reimbursement,
neither requiring a welfare plan to contain a subrogation clause, nor baring such a
clause or otherwise regulating its content. See Member Servs. Life Ins. Co. v.
American Nat. Bank and Trust Co. of Sapula, 130 F.3d 950, 958 (10 th Cir. 1997)
(citing Ryan v. Federal Express Corp., 78 F.3d 123, 127 (3d Cir. 1996)). ERISA,
of course, preempts state law dealing with the interpretation of an ERISA-
governed plan unless the plan involves the purchase of an insurance policy as the
method of providing plan benefits. See FMC Corp. v. Holliday, 498 U.S. 52, 111
S.Ct. 403, 112 L.Ed.2d 356 (1990) (holding a state subrogation rule preempted). 2
In the absence of such statutory guidance, federal courts may create federal
common law for the use in ERISA cases. See Pilot Life Ins. Co. v. Dedeaux, 481
U.S. 41, 56, 107 S.Ct. 1549, 1557-58, 95 L.Ed.2d 39 (1987); see also Cutting v.
2
There is some authority that state subrogation laws, such as a state’s Make
Whole rule, would not be preempted in cases involving insured ERISA plans, rather than
self-funded plans. See Blue Cross & Blue Shield of Alabama v. Fondren, 966 F.Supp.
1093, 1097 (M.D.Ala. 1997).
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Jerome Foods, Inc., 993 F.2d 1293, 1297 (7 th Cir. 1993) (“[Federal] courts have to
adopt some interpretive principles, even if only implicit ones, in order to construe
ERISA plans, since ERISA sets forth no principles of interpretation of its own.
And those principles that the judges devise or adopt to guide their interpretations
are therefore common law, that is judge made, principles.”). In adopting a rule of
interpretation as federal common law, this court has previously stated that it is
“guided by the Supreme Court’s admonition that ‘ERISA was enacted to promote
the interests of employees and their beneficiaries in employee benefit plans, and
to protect contractually defined benefits.’” Member Servs., 130 F.3d at 954(quoting Firestone Tire, 489 U.S. at 113, 109 S.Ct. at 956 (internal quotations and
citations omitted)). However, this court has also cautioned that “‘the power [of
federal courts] to develop common law pursuant to ERISA does not give carte
blanche power to rewrite the legislation to satisfy [the court’s] proclivities.’
Instead, the courts must continue to implement the policies of ERISA.”
Resolution Trust Corp. v. Financial Insts. Retirement Fund, 71 F.3d 1553, 1556
(10 th Cir. 1995); see also Sunbeam-Oster Co. Group Benefits Plan v. Whitehurst,
102 F.3d 1368, 1374 (5 th Cir. 1996) (“[E]ven though we may borrow from
analogous state law when it is not inconsistent with congressional policy
concerns, our formulation of federal common law in the instant situation must
remain guided foremost by the congressional policies expressed or implicit in
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ERISA.”).
In this case, the Alves urge the court to adopt the Make Whole doctrine
under federal common law for the interpretation of ERISA plans. Because the
expected total recovery from the third-party tortfeasor (the $ 100,000.00 offer
from the tortfeasors insurer) would not “make whole” their actual damages ($
103,514.24), the Plan would have no right to reimbursement of any benefits paid.
Thus, the proposed reimbursement acknowlegment forms expanded the Plans
rights to reimbursement and the Plan’s refusal to pay benefits until the Alves
signed either reimbursement acknowledgment form constituted a wrongful denial
of benefits and breach of the Plan’s fiduciary duties. 3
The Make Whole doctrine is a creature of equitable insurance law and is
generally stated as:
3
The district court in Cagle v. Bruner, 921 F.Supp. 726 (M.D.Fla. 1995), aff’d
and remanded, 112 F.3d 1510 (11th Cir. 1997) concluded an ERISA plan abused its
discretion by conditioning the payment on benefits on the signing of a supplemental
subrogation form because the supplemental form expanded the plan’s ability to recover
beyond what was described in the SPD. See id. at 740. The Eleventh Circuit, however,
reversed this specific ruling on the basis the SPD stated that “[the participant or
beneficiary] may be asked to execute documents or take such other action as is necessary
to assure the rights of the Fund.” Cagle v. Bruner, 112 F.3d 1510, 1520 (11th Cir. 1997).
The court reasoned “[t]hat language can be read to require execution of the subrogation
agreement before payment as easily as it can be read to require execution of the
agreement after payment. Thus, the Fund’s interpretation is not unreasonable, given the
language of the plan.” Id. The Eleventh Circuit did not discuss whether the supplemental
subrogation agreement broadened the rights of the ERISA plan over those rights granted
to it in the SPD.
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in the absence of contrary statutory law or valid contractual
obligations to the contrary, the general rule under the doctrine of
equitable subrogation is that where an insured is entitled to receive
recovery for the same loss from more than one source, e.g., the
insurer and the tortfeasor, it is only after the insured has been fully
compensated for all of the loss that the insurer acquires a right to
subrogation, or is entitled to its subrogation rights. The rule applies
as well to instances in which the insured has recovered from the
third party and the insurer attempts to exercise its subrogation right
by way of reimbursement against the insured’s recovery.
16 Couch on Insurance 3d § 223:134 at 147-150 (2000) (footnotes omitted). As
the Fifth Circuit explained in Sunbeam-Oster Co., the Make Whole doctrine is
one of three alternative rules a court could apply in establishing a ranking or
priority between the Plan and the beneficiary in a partial recovery situation. See
Sunbeam-Oster Co., 102 F.3d at 1373-74. The other two include a “Plan Priority”
rule, under which priority is given to the ERISA plan for full recovery “off the
top.” Id. The other is a “Pro Rata” system, under which the plan and the
beneficiary share ratably in the beneficiary’s recovery from third parties. See id.
at 1374.
The Tenth Circuit has not yet had the opportunity to determine which
priority ranking plan is to be adopted for purposes of ERISA plan interpretation.
Several of our sister circuits have adopted the Make Whole rule into federal
common law as a default rule. See, e.g., Copeland Oaks v. Haupt, 209 F.3d 811,
813-14 (6 th Cir. 2000); Cagle v. Bruner, 112 F.3d 1510, 1521-22 (11 th Cir. 1997);
Barnes v. Indep. Auto. Dealers Ass’n of Cal., 64 F.3d 1389,1394-95 (9 th Cir.
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1995). Other circuit courts have declined to do so. See, e.g., Harris v. Harvard
Pilgrim Health Care, Inc., 208 F.3d 274, 280-81 (1 st Cir. 2000) (declining
adoption of Make Whole rule because rule conflicts with policy objectives of
ERISA); Waller v. Hormel Foods Corp., 120 F.3d 138, 140 (8 th Cir. 1997)
(finding standard subrogation language in SPD provided plan with priority
subrogation rights and rejecting Make Whole rule because reasons for adoption
under insurance law do not transport easily into employee benefit plans);
Sunbeam-Oster Co., 102 F.3d at 1378 (stating, in dicta, that even in absence of
standard subrogation language in the SPD, it doubted it would adopt Make Whole
doctrine as a default rule).
The Alves urge the court to adopt the Make Whole doctrine as federal
common law for the interpretation of ERISA plans. The Plan, on the other hand,
takes the position that even if the court were to adopt the Make Whole doctrine,
the doctrine is only a default rule and that it specifically rejected the doctrine in
its SPD by its provision of a plan priority rule. Furthermore, the Plan argues that
the real question is whether it abused its discretion in interpreting the SPD
language as providing for a plan priority reimbursement. The district court
agreed with the Plan’s argument and we now affirm.
Although this circuit has not yet had the opportunity to decide which
priority rule to apply to ERISA plans, we do have guidance from a previous
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diversity case in which we were asked to explore the Make Whole doctrine under
Oklahoma law. See Fields v. Farmers Ins. Co., Inc., 18 F.3d 831 (10 th Cir. 1994).
Similar to the facts in this case, the plaintiff in Fields, a beneficiary under a
private insurance policy, sought a declaratory judgment that, because his total
injuries exceeded the amount he recovered from third-parties, the insurance
company could not be reimbursed from monies received from the third-parties.
See id. at 834. After determining that no directly on-point Oklahoma authority
existed on the issue, this court determined that even if Oklahoma were to adopt
the Make Whole doctrine, the parties sufficiently contracted out of what is
considered a default rule by the standard subrogation language contained in the
insurance policy. See id. at 834-36. Specifically, the policy provided:
SUBROGATION
Subrogation means the Plan’s right to recover any of its
payments (1) made because of any injury to you or your
dependent caused by a third party and (2) which you or your
dependent later recover from the third party or the third party’s
insurer.
SUBROGATION RIGHTS
If you or your dependent sustain an injury caused by a third
party, the Plan will pay for the injury, subject to (1) the Plan
being subrogated to any recovery or any right of recovery you
or your dependent has against that third party, including the
right to bring suit in your name; (2) your not taking any action
which would prejudice the Plan’s subrogation right; and (3)
your cooperating in doing what is reasonably necessary to
assist the Plan in any recovery. The Plan will be subrogated
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only to the extent of Plan benefits paid because of the injury.
Id. at 834-35. Although the Oklahoma Supreme Court had applied the Make
Whole doctrine in a case of equitable subrogation, see id. at 835 (citing Gentry
(L.A.), d/b/a/ Gentry Enters., Inc. v. American Motorist Ins. Co., 867 P.2d 468(Okla 1994)), this court refused to expand that holding to a case involving an
insurance policy containing a subrogation clause. This court noted that those
jurisdictions which have adopted the Make Whole doctrine have done so as a
mere default rule and allow the rule to be overridden by a provision in an
insurance contract. See id. The above quoted subrogation language, this court
found, was such an overriding provision:
Here, the clear language of the insurance contract provides that
[the insurance company] shall be subrogated to any recovery that
plaintiff receives from the negligent third party or its insurer.
Plaintiff has not identified, nor have we discerned, public policies
that would compel the Oklahoma court to disregard the clear and
unambiguous subrogation provisions of this insurance contract.
Id. at 836.
Those circuits which have adopted the Make Whole doctrine for the
interpretation of ERISA plans have only done so to the extent the doctrine
represents a default rule. In this case, there is no need for us to determine the
default rule because, like the insurance policy in Fields, the Plan’s SPD
specifically provided for reimbursement from third-party recovery. If we were to
find the standard subrogation language in Fields sufficient to override a possible
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default Make Whole rule, certainly we should find the specific priority language
found in the Plan’s SPD to be more than adequate. The Plan’s SPD language
went beyond the language contained in the Fields insurance contract. The
language provided that the Plan’s subrogation and reimbursement rights “provide
the Plan with a priority over any funds paid by a third party. . . .” (Summary Plan
Description at 34) (emphasis added). Even the Eleventh Circuit would find such
language sufficient to override the Make Whole doctrine and provide the Plan
with a priority over third-party recovery. See Cagle v. Bruner, 112 F.3d 1510,
1521-22 (11 th Cir. 1997) (holding standard subrogation language insufficient to
overcome the Make Whole doctrine, even in cases applying an arbitrary and
capricious standard of review). The Plan’s use of the word priority in its
subrogation clause “specifically allowed the Plan the right of first reimbursement
out of any recovery [the Alves were] able to obtain even if [the Alves] were not
made whole.” Barnes v. Indep. Auto. Dealers of Cal., 64 F.3d 1389, 1395 (9 th
Cir. 1995) (quoted in Cagle, 112 F.3d at 1522). Cf. Sanders v. Scheideler, 816
F.Supp. 1338, 1347 (W.D.Wis. 1993) (adopting Make Whole rule, but only as “a
default rule to be applied only when a plan fails to designate priority rules or
provide its fiduciaries with the discretion necessary to construe the plan
accordingly.”).
BREACH OF FIDUCIARY DUTY
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ERISA’s section 404(a) provides that “a fiduciary shall discharge his duties
with respect to a plan solely in the interest of the participants and beneficiaries
and . . . in accordance with the documents and instruments governing the plan
insofar as such documents and instruments are consistent with the provisions of
[ERISA].” 29 U.S.C. § 1104; see also Varity Corp. v. Howe, 516 U.S. 489, 505,
116 S.Ct. 1065, 1074, 134 L.Ed.2d 130 (1996) (stating that a fiduciary’s knowing
and significant participation in the deception of a plan’s beneficiary “in order to
save the employer money at the beneficiaries’ expense” constitutes a breach of
fiduciary duty under ERISA). The Alves contend the Plan breached its duty to
them by (1) refusing to pay the medical bills; (2) requiring the Alves to sign
either of the two offered reimbursement acknowledgment forms; and (3) soliciting
the Alves’ attorney to represent the Plan’s interests in the case against the third-
party tortfeasor. We address each claim in turn.
First, the Alves claim the Plan breached its fiduciary duty to them by not
paying and processing their claims. The Alves focus on the district court’s
finding that the Plan’s right of subrogation does not vest until after the Plan pays
benefits and they argue that “[i]nstead of first paying the medical benefits due
under the terms of the plan in a timely manner, the Plan instead focused on its
claimed right of subrogation and refund.” Appellants’ Brief at 14. The Alves,
however, confuse the Plan’s right of subrogation and its right to require the Alves
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to sign a document recognizing its right to later subrogation and reimbursement.
The Plan’s SPD provides that:
When a right of recovery exists, the Covered Person will execute and
deliver all required instruments and papers as well as doing whatever
else is needed to secure the Plan’s right of subrogation as a
condition to having the Plan make payments.
(Summary Plan Description at 34) (emphasis added). Although the right of
subrogation did not technically exist, the Plan did not act arbitrarily and
capriciously in requiring the Alves to sign a reimbursement acknowledgment form
prior its paying medical benefits based on the above cited language of its SPD. In
Cagle v. Bruner, 112 F.3d 1510 (11 th Cir. 1997), the Eleventh Circuit, faced with
a similar argument, came to the same conclusion:
On the “reasonable interpretation” factor, the district court
determined that the Fund unreasonably interpreted the plan to allow
it to require a signed subrogation agreement prior to paying benefits.
According to Bruner, the district court correctly found the Fund’s
position to be unreasonable, because the Fund has no right of
subrogation until benefits are paid. We believe that Bruner is
confusing the issues. It is true that because the Fund has no right of
subrogation until the plan pays benefits, it cannot enforce the
subrogation agreement until it pays benefits. Nevertheless, nothing
in the plan forbids the Fund from requiring the agreement to be
signed before it pays any claims. The SPD states that “[the
participant or beneficiary] may be asked to execute documents or
take such other action as is necessary to assure the rights of the
Fund.” That language can be read to require execution of the
subrogation agreement before payment as easily as it can be read to
require execution of the agreement after payment. Thus, the Fund’s
interpretation is not unreasonable, given the language of the plan.
When we consider the practical reasons for requiring the
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subrogation agreement to be signed before paying any benefits, the
reasonableness of that policy becomes abundantly clear. The Fund
uses the subrogation agreements in negotiations with at-fault third
parties. Once benefits are paid, participants and beneficiaries have
little incentive (other than the fear of a lawsuit) to sign a subrogation
agreement. If the Fund cannot require the agreement beforehand, it
often will have to resort to lawsuits or at least the threat of lawsuits
to obtain the agreements. Lawsuits cost money, sometimes a lot of
it. In addition, delay becomes inevitable, and while the Fund is
attempting to obtain the agreements from participants and
beneficiaries, the Fund is hampered in its negotiations with at-fault
third parties. In short, having the agreement in hand before paying
benefits provides significant protection to trust assets. Cost concerns
weigh in favor of the Fund’s policy.
Id. at 1520.
Next, the Alves contend the Plan breached its fiduciary duty by requiring
them to sign a reimbursement agreement which “impermissibly broadened the
Plan’s rights beyond those contained in the Plan document.” Appellants’ Brief at
15. The district court found the first offered reimbursement acknowledgment
form did not broaden the Plan’s rights from those in the SPD. As explained
above, the Plan had a right to a priority reimbursement from any recovery from a
third-party. The district court did find the second offered supplemental
reimbursement acknowledgment form to provide the Plan with rights not provided
to it under the terms of the plan. However, as the district court explained, the
Alves were not harmed by such a discrepancy because the Plan would have paid
the claims had the Alves signed the first offered reimbursement agreement.
Last, we affirm the district court’s finding that the Plan did not breach its
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fiduciary duty to the Alves by attempting to hire their attorney. As with their
motion for summary judgment before the district court, the Alves, in their brief,
again rely on a letter from the third party administrator, Johnson Brokers and
Administrators, to their attorney. To the extent the solicitation could be deemed
inappropriate, the Alves once again fail to make any argument in favor of
attributing the letter to the Plan. Thus, the Plan could not have breached its
fiduciary duty to the Alves based on the third-party administrator’s conduct.
CONCLUSION
For the above reasons, we AFFIRM the decision of the district court.
Entered for the Court,
Monti L. Belot
District Judge
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