DocketNumber： 3-96-0792
Citation Numbers： 287 Ill. App. 3d 796
Filed Date： 4/23/1997
Status： Precedential
Modified Date： 1/12/2023
No. 3--96--0792
_________________________________________________________________
IN THE
APPELLATE COURT OF ILLINOIS
THIRD DISTRICT
MARIE A. BOYD, ) Appeal from the Circuit
) Court of the 10th
Plaintiff-Appellant, ) Judicial Circuit,
) Tazewell
) County, Illinois
)
v. ) No. 94-L-5
)
PEORIA JOURNAL STAR, INC., )
an Illinois Corporation, ) Honorable
) Donald C. Courson
Defendant-Appellee. ) Judge, Presiding
_________________________________________________________________
JUSTICE MICHELA delivered the Opinion of the court:
________________________________________________________________
Marie A. Boyd, filed an action in the circuit court of
Tazewell County against her employer, Peoria Journal Star, Inc.,
seeking recovery for medical expenses under a health insurance
plan known as "The Peoria Journal Group Health Benefit Plan" (the
Plan). The court granted defendant's motion for summary judgment
and denied plaintiff's counter-motion for summary judgment.
On appeal, plaintiff seeks reversal of the court's decision,
contending that it erred in finding the Plan contained no
provisions for, and specifically excluded coverage for, the
surgical removal of her defective prosthesis. Plaintiff contends
further that defendant's interpretation of the Plan was
irrational, arbitrary, and capricious, in violation of the
Employee Retirement Income Security Act (ERISA)(29 U.S.C. section
1132(1)(B)(1991)). In the alternative, plaintiff requests that
this court find that defendant's select review of medical
evidence created a question of fact as to whether defendant's
decision was arbitrary and capricious, and remand the cause for
further proceedings. For the following reasons, we reverse.
Facts
In March 1983, plaintiff developed temporomandibular joint
syndrome (TMJS), which necessitated the replacement of her
temporomandibular joint (TMJ) with a TMJ implant (prosthesis).
In October 1993, plaintiff's oral surgeon, Dr. Russell A.
Williams, notified defendant that due to resorption occurring
around plaintiff's prosthesis, and the potential for brain
exposure, her prosthesis must be removed. Dr. Williams informed
defendant of his surgical plan, and surgery was scheduled for
November 1993. Prior to surgery, defendant notified Dr. Williams
and plaintiff of its denial of plaintiff's benefit claim.
In January 1994, plaintiff filed her complaint against
defendant, which was later amended, and alleged, inter alia, that
in violation of ERISA, defendant's decision to deny her benefits
was based on an irrational, arbitrary, and capricious
interpretation of the Plan.
In April 1994, plaintiff underwent surgical removal of her
prosthesis at a reported cost of $30,000. In December 1994,
defendant filed a motion for summary judgment, and in May 1995,
plaintiff filed a counter-motion for summary judgment. In August
1995, the court granted defendant's motion, denied plaintiff's
counter-motion, and plaintiff appeals.
Analysis
Plaintiff contends that the court erred in granting
defendant's motion for summary judgment and in denying her
counter-motion for summary judgment. A motion for summary
judgment should be granted if the pleadings, depositions, and
admissions on file, together with any affidavits, show that there
is no genuine issue of material fact and that the moving party is
entitled to a judgment as a matter of law. Boylan v. Martindale,
103 Ill. App. 3d 335, 339 (1982).
In this matter, plaintiff asserts that the court erred in
finding that the Plan contained no provisions for, and
specifically excluded coverage for, the surgical removal of her
defective prosthesis. Plaintiff maintains that in violation of
ERISA, defendant's interpretation of the Plan was unreasonable,
arbitrary, and capricious.
When a trustee is given the discretion to construe a plan's
terms and allocate benefits, judicial review is limited to
whether that decision was arbitrary and capricious. Russo v.
Health, Welfare & Pension Fund, 984 F.2d 762, 765 (7th Cir.
1993). The arbitrary and capricious standard only requires that
a trustee's decision make sense, and something more than an
alternative interpretation is needed to override such decision.
Russo, 784 F.2d at 766. Great deference is given to the
trustees' decision, and it will not be disturbed when it is based
on a reasonable interpretation of a plan's language and evidence
in the case. Russo, 784 F.2d at 765.
We note that while it is axiomic that contracts are
considered as a whole, and are not read in isolated pieces
[citations], full effect should be given to more principle and
specific clauses, and general clauses should be subject to
modification or qualification necessitated by specific clauses.
Herington v. J.S. Alberici Construction Co., 266 Ill. App. 3d
489, 493 (1994).
In support of her position that the Plan does provide her
with coverage, plaintiff relies in part upon subsections (c) and
(e) of the Plan's deductible medical benefits section, which
grant coverage for such things as in-patient hospital services,
physicians' surgical services, anesthetics, and radiologist or
laboratory services. However, plaintiff acknowledges that in
addition to its own stated limitations, the Plan's deductible
medical benefits section is subject to the exclusions found in
the Plan's general limitations section. The general limitations
section states in pertinent part:
"In addition to any limitations or exclusions stated in
the respective benefit descriptions, no benefits are
payable under this Plan for Expenses Incurred:
***
(c) for or in connection with:
***
(20) treatment of temporomandibular joint syndrome
with intraoral prosthetic devices, or any other
procedure to alter vertical dimension," (Emphasis
added.)
In determining whether an "in connection with" exclusion
applies, the court in Kraut v. Wisconsin Laborers Health Fund,
992 F.2d 113, 114 (7th Cir. 1993) stated that the purpose rather
than the location of the surgery is the critical inquiry.
In the present matter, on November 17, 1993, Dr. Williams
wrote to defendant and requested that it reconsider its decision
denying plaintiff benefits. In doing so, Dr. Williams thoroughly
explained his position as to why plaintiff's surgery did not fall
within the exclusion "for or in connection with" the treatment of
TMJS with intraoral devices, or any procedure to alter vertical
dimension. Dr. Williams noted, inter alia, that plaintiff
neither has, nor shows symptoms of, TMJS, and that her prosthesis
must be removed due to resorption.
Further, a May 1995 affidavit from Dr. Williams re-
emphasizes the purpose of plaintiff's surgery. Importantly, Dr.
Williams states therein that:
"[i]n 1992, 1993, and 1994, I did not treat Marie Boyd for
or in connection with [TMJS] or any other procedure to alter
vertical dimension. Marie had no symptoms or clinical
findings attributable to [TMJS]. No intraoral devices were
utilized in her surgery. Any alteration of vertical
dimension would be considered a problem or complication of
the surgery to remove the protheses ***."
Defendant failed to present medical evidence to refute Dr.
Williams' opinion as to the purpose of plaintiff's surgery.
Although defendant's employee relation's manager, John Swingle
(Swingle), testified at his deposition that he left it up to the
Plan's third party administrator, Employee Benefits Corporation
(EBC), to "look at [plaintiff's] symptoms or procedures or
whatever was involved ***," he stated that EBC did not provide,
nor did he request, any written document outlining their reasons
for recommending denial of benefits.
In further response to his failure to consider plaintiff's
resorption symptoms, Swingle stated, "[t]he point was that
removal of the implants, in my opinion and the opinion of the
EBC, was most certainly related to the original TMJ surgery."
Swingle's comment suggests that the decision to deny plaintiff
benefits was exclusively based on the fact that in 1983 she
suffered from TMJS and underwent a surgical replacement of her
TMJ with a prosthesis.
We find that defendant's reading of the Plan was neither
based on a reasonable interpretation of the Plan's language, nor
on the evidence presented. Dr. Williams' correspondence, coupled
with his affidavit, establishes that the 1994 surgical removal of
plaintiff's prosthesis, where no intraoral devices were used, was
neither a procedure which treated or was in connection with her
1983 TMJS, nor was it performed to alter her vertical dimension.
Therefore, section (c)(20) of the Plan's general limitations
section does not bar plaintiff's claim for benefits. As no
material question of fact exists, plaintiff is entitled to
summary judgment as a matter of law.
Under these circumstances, the court erred in granting
defendant's motion for summary judgment and in denying
plaintiff's counter-motion for summary judgment. In light of our
disposition of this issue, it is unnecessary for us to consider
plaintiff's alternative contention regarding defendant's alleged
select review of medical evidence.
Based on the foregoing, we reverse the Tazewell County
circuit court's grant of defendant's motion for summary judgment
and denial of plaintiff's counter-motion for summary judgment.
Reversed.
LYTTON, P.J., and SLATER, J., concurred.