Donaldson v. LA Hlth Svcs & Indem

UNITED STATES COURT OF APPEALS
For the Fifth Circuit
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No. 96-30601
Summary Calendar
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CONNIE DONALDSON, wife of/and JOHN DONALDSON,
Plaintiffs-Appellants,
VERSUS
LOUISIANA HEALTH SERVICE AND INDEMNITY COMPANY
D/B/A BLUE CROSS BLUE SHIELD OF LOUISIANA
Defendant-Appellee.
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Appeal from the United States District Court
for the Eastern District of Louisiana
(94-CV-1821-F)
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December 30, 1996
Before REYNALDO G. GARZA, HIGGINBOTHAM, and DeMOSS, Circuit Judges.
PER CURIAM:*
Connie D. Donaldson and John D. Donaldson, the appellees, were
participants in an employee welfare benefit plan issued through Mr.
Donaldson’s employer, Jones Brothers Supply, Inc. Blue Cross Blue
Shield, the appellant, issued a group medical benefits policy
covering that plan. Mrs. Donaldson was covered under the policy
issued by Blue Cross Blue Shield effective April 1, 1993.
On July 5, 1993, Mrs. Donaldson sought emergency treatment in
*
Local Rule 47.5 provides: “The publication of opinions that have no precedential value and
merely decide particular cases on the basis of well-settled principles of law imposes needless expense
on the public and burdens on the legal profession.” Pursuant to this Rule, the Court has determined
that this opinion should not be published.
the East Jefferson Emergency Room for severe epigastric pain
radiating to her back, nausea, and vomiting. She relayed to the
treating physician that she had been experiencing intermittent
abdominal pain which felt like “gas” over the past 11 months, just
two months after she delivered a baby. She was diagnosed with
gallstones by the use of ultrasound, but her symptoms subsided and
she was discharged. On July 8, 1993, Mrs. Donaldson again went to
the emergency room with similar pain, nausea and vomiting. The
pain subsided and she was once again discharged. On July 13, 1993,
Mrs. Donaldson was readmitted and Dr. Richard Karlin performed an
endoscopic cholecystectomy (surgical removal of the gallbladder).
Blue Cross denied coverage claiming that Mrs. Donaldson’s illness
fell under the pre-existing condition exclusion of the Blue Cross
policy.
Dr. Richard M. Karlin, Mrs. Donaldson’s treating physician,
submitted a letter stating that Mrs. Donaldson was a woman who had
no proven history of gall stones and that her condition was not
pre-existing. Dr. William M. Meyers, her emergency room physician,
wrote a letter clearly stating that Mrs. Donaldson’s gall bladder
symptoms arose shortly before her hospitalization. Blue Cross
still denied coverage. The Donaldsons filed suit and the case was
removed under the Employee Retirement Income Securities Act of
1974, 29 U.S.C. § 1001, et seq. The plaintiffs then moved for
summary judgment.
A hearing took place on May 3, 1995, wherein Magistrate Judge
Ivan Lemelle of the Eastern District of Louisiana, granted
plaintiffs’ motion and remanded the case to Blue Cross for further
investigation into the existence of a pre-existing condition.
On remand, Blue Cross’s Medical Director, Dr. J.G. Gengelbach
reviewed the claim and affirmed the denial of coverage. Dr.
Gengelbach’s conclusion was based on the assertion that pregnant
patients “generally” become symptomatic after delivery and that
this appeared to be the case with Mrs. Donaldson. No further
investigation was conducted by Blue Cross.
The plaintiffs then filed a motion for summary judgment and
Blue Cross filed a cross motion for summary judgment. A hearing
was held before Magistrate Judge Lemelle on May 1, 1996. On June
12, 1996, he granted plaintiffs’ motion and denied Blue Cross’s
motion.
Upon applying the applicable standard of review and reviewing
the facts in the record as well as the parties’ briefs, we find
that, under the law, the lower court did not err in granting
plaintiffs’ summary judgment or awarding attorney’s fees.
AFFIRMED.