Samuel v. Citibank, N.A. Long Term Disability Plan, No. 4:2007cv04051 - Document 60 (D.S.D. 2009)
Court Description: OPINION AND ORDER RE: SUMMARY JUDGMENT MOTIONS denying without prejudice 46 Motion for Summary Judgment; denying without prejudice 47 Motion for Summary Judgment; granting 55 Amended Motion to Strike; denying as moot 34 Motion to Strike. Signed by U.S.Magistrate Judge John E. Simko on 3/13/09. (Attachments: # 1 Gugin v. J.C. Penney Company) (DJP)
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Page 20f6 Westlaw. Page I 242 F.3d 374 242 F.3d 374, 2000 WL 1728303 (CA8 (Ark.)) (Table, Text in WESTLAW), Unpublished Disposition (Cite as: 242 F.3d 374,2000 WL 1728303 (C.A.8 (Ark.))) C 23IHVll(K)5 Actions to Recover Benefits 231 Hk684 Standard and Scope of Re NOTICE: THIS IS AN UNPUBLISHED OPIN I~. vkw (The Court's decision is referenced in a "Table of Decisions Without Reported Opinions" appearing in the Federal Reporter. Use FI CTA8 Rule 28A, FI CTA8 lOP and FI CTA8 APP. I for rules regarding the citation of unpublished opinions.) United States Court of Appeals, Eighth Circuit. James GUGIN, Appellee, v. lC. PENNEY COMPANY, Inc. Voluntal)' Em ployees Beneficiary Association Medical Benefit Plan, Appellant. No. 98-3635, 98-3989, 98-4011. Submitted Nov. 15,2000. Filed Nov. 22, 2000. ERISA plan beneficial)' brought suit challenging denial of benefits for a portion of time he was hos pitalized for post-stroke psychiatric and related problems, and for his subsequent treatment at resid ential facility. The United States District Court for the Western District of Arkansas entered judgment granting beneficial)' partial relief, and awarded at torney fees. Plan appealed. The Court of Appeals held that: (I) plan administrator abused its discre tion by refusing to extend deadline for filing admin istrative appeal; (2) beneficiary was entitled to be nefits for hospitalization, and for portion of time in residential facility; and (3) court failed to consider necessary factors in making award of attorney fees. Affirmed in part, vacated in part, and remanded. West Headnotes 231 Hk688 k. Abuse of Discretion. Most Cited Cases (Formerly 296k139) Denial of benefits by ERISA plan administrator was subject to judicial review under abuse of dis cretion standard, where terms of plan gave plan ad ministrator the exclusive right and discretion to in terpret, to rule on plan language, and to determine coverage. Employee Retirement Income Security Act of 1974, §2etseq.,29U.S.C.A. § 1001 etseq. 121 Federal Courts 1708 ~776 170B Federal Courts 170BVllI Courts of Appeals 170BVlIl(K) Scope, Standards, and Extent 170BVlIl(K) I In General 170Bk776 k. Trial De Novo. Most Cited Cases Court of Appeals reviews de novo determination by district court as to whether administrator of ERISA plan abused its discretion in interpreting plan, and ruling on coverage under plan. Employee Retire ment Income Security Act of 1974, § 2 et seq., 29 U.S.C.A. § 100 I et seq. 13] Labor and Employment 231H ~685 231 H Labor and Employment 231 HVII Pension and Benefit Plans 23IHVII(K) Actions 231 HVII(K)5 Actions to Recover Benefits 231 Hk684 Standard and Scope of Re view 23 IHk685 k. In General. Most Cited Cases (Formerly 296k139) (I J Labor and Employment 231H ~688 Labor and Employment 231H ~691 231 H Labor and Employment 231 HVIl Pension and Benefit Plans 23\ HVII(K) Actions 231 H Labor and Employment 231 Hvrr Pension and Benefit Plans © 2009 Thomson Reuters/West. No Claim to Orig. US Gov. Works. http://web2.westlaw.com/print/printstream.aspx?prft=HTMLE&destination=atp&sv=Split&rs=WLW9.02... 3/13/2009 Page 3 of6 242 F.3d 374 242 F.3d 374, 2000 WL 1728303 (C.A.8 (Ark.» (Table, Text in WESTLAW), Unpublished Disposition (Cite as: 242 F.3d 374, 2000 WL 1728303 (C.A.8 (Ark.))) 23 I HVII(K) Actions 231 HVII(K)5 Actions to Recover Benefits 231 Hk691 k. Record on Review. Most Cited Cases (Fonnerly 296k 139) Discretionary detenninations by administrator of ERISA plan regarding plan interpretation, and cov erage under plan, are reviewed to detennine wheth er they are supported by substantial evidence, con sidering only the evidence that was before the ad ministrator, and court must affinn if a reasonable person could have reached a similar decision, given the evidence before him, not merely if a reasonable person would have reached that decision. 141 Labor and Employment 231H ~623 23 IH Labor and Employment 231 HVII Pension and Benefit Plans 231 HVII(J) Detennination of Benefit Claims by Plan 231 Hk620 Administrative Review 231Hk623 k. Time Limitations. Most Cited Cases (Fonnerly 296k135) Administrator of ERISA plan abused its discretion by refusing to extend deadline for filing adminis trative appeal challenging administrator's decision to deny medical benefits under plan for a portion of time that plan beneficiary was hospitalized for post stroke psychiatric and related problems, and for his later treatment at residential facility. Employee Re tirement Income Security Act of 1974, § 2 et seq., 29 U.S.C.A. § 100 I et seq. (5) Insurance 217 ~2494(2) 217 Insurance 2l7XX Coverage--Health and Accident Insur ance 217XX(B) Medical Insurance 217k2493 Settings for Care; Service Or ganizations 217k2494 In-Patient Hospital Treat ment 217k2494(2) k. Mental or Emotion- Page 2 al Disorders. Most Cited Cases Labor and Employment 231H ~565 23 IH Labor and Employment 23 1HVII Pension and Benefit Plans 231 HVlI(H) Coverage and Benefits of Par ticular Types of Plans 23 IHk564 Medical and Health Plans 231 Hk565 k. In General. Most Cited Cases (Fonnerly 296k 121) Administrator of ERISA plan abused its discretion by detennining that plan beneficiary was not en titled to medical benefits to cover a portion of cost for period in which he was hospitalized for treat ment of his post-stroke psychiatric and related problems. Employee Retirement Income Security Act of 1974, § 2 et seq., 29 U.S.C.A. § 1001 et seq. 161 Insurance 217 ~2494(2) 217 Insurance 217XX Coverage--Health and Accident Insur ance 217XX(B) Medical Insurance 217k2493 Settings for Care; Service Or ganizations 217k2494 In-Patient Hospital Treat ment 217k2494(2) k. Mental or Emotion al Disorders. Most Cited Cases Labor and Employment 231H ~567 231 H Labor and Employment 231 HVII Pension and Benefit Plans 231 HVIl(H) Coverage and Benefits of Par ticular Types of Plans 231 Hk564 Medical and Health Plans 231 Hk567 k. Treatments and Benefits Covered. Most Cited Cases (Fonnerly 296k121) Administrator of ERISA plan did not abuse its dis cretion by detennining that plan beneficiary was not entitled to medical benefits under plan covering © 2009 Thomson Reuters/West. No Claim to Orig. US Gov. Works. :p :llweb2. westlaw.com/print/printstream.aspx?prft=HTMLE&destination=atp&sv=Split&rs=WLW9.02... 3/13/2009 Page 4 of6 242 F.3d 374 242 F.3d 374, 2000 WL 1728303 (C,A,8 (Ark.» Page 3 (Table, Text in WESTLAW), Unpublished Disposition (Cite as: 242 F.3d 374,2000 WL 1728303 (C.A.8 (Ark.») cost of treatment at residential facility for post stroke psychiatric and related problems, based on finding of its reviewing physicians that such care was medically unnecessary. Employee Retirement Income Security Act of 1974, § 2 et seq., 29 U.S.C.A. § 1001 et seq. 171 Federal Courts 170B ~830 170B Federal Courts 170BVllI Courts of Appeals 170BVllI(K) Scope, Standards, and Extent 170BVllJ(K)4 Discretion of Lower Court 1l:70Bk830 Costs, Attorney's Fees and Other Allowances. Most Cited Cases Award of attorney fees in an ERISA case is re viewed for abuse of discretion. Employee Retire ment Income Security Act of 1974, § 2 et seq., 29 U.S.C.A. § 1001 et seq. 231 Hk713 Particular Cases 231 Hk717 k. Actions to Recover Benefits. Most Cited Cases (Formerly 296k143) District court abused its discretion by awarding at torney fees to ERISA plan beneficiary in its action challenging plan administrator's denial of benefits, where court considered only amount of recovery, and did not consider additional appropriate factors, including plan's culpability or bad faith, its ability to pay, deterrent effect an award would have on others, and the relative merits of the parties' posi tions. Employee Retirement Income Security Act of 1974, § 2 et seq., 29 U.S.C.A. § 1001 et seq. Appeals from the United States District Court for the Western District of Arkansas. Before BOWMAN, FAGG, and BEAM, Circuit Judges. 181 Labor and Employment 231H ~711 231 H Labor and Employment 23 IHVII Pension and Benefit Plans 231 HVll(K) Actions 23 IHVII(K)8 Costs and Attorney Fees 23 ]Hk71 J k. Factors Considered in General. Most Cited Cases (Formerly 296k143) In deciding whether to award attorney fees in an ERISA case, district court should consider, in addi tion to amount of recovery, the opposing party's culpability or bad faith, its ability to pay, the de terrent effect an award would have on others, whether the requesting party sought to benefit all participants or to resolve a significant ERISA legal question, and the relative merits of the parties' posi tions. Employee Retirement Income Security Act of 1974, § 2 et seq., 29 U.S.C.A. § 100 I et seq. 191 Labor and Employment 231H ~717 231 H Labor and Employment 231 HVII Pension and Benefit Plans 231 HVIl(K) Actions 231HVIl(K)8 Costs and Attorney Fees PER CURIAM. *1 J.C. Penney Company, Inc. Voluntary Employ ees Beneficiary Association Medical Benefit Plan ("the Plan"), set up under the Employment Retire ment Security Act of 1974 (ERISA), denied medic al benefits to Plan participant James Gugin for a portion of the time he was hospitalized for post stroke psychiatric and related problems, and for his later treatment at Timber Ridge Ranch (Timber Ridge), based on the finding of its reviewing physi cians that the care was medically unnecessary. The Plan also denied as untimely one of Gugin's admin istrative appeals. After Gugin brought suit under 29U.S.C. § 1132(a)(1)(B) for wrongful denial of benefits, the district court decided (I) the adminis trative appeal should be deemed timely; (2) Gugin was entitled to recover benefits for his hospitaliza tion; (3) although Gugin was not entitled to recover the costs of Timber Ridge, he should recover the cost of certain alternative care for the period of time he spent there; and (4) he was entitled to attor ney fees of $8,400. The Plan appeals the district court's award of benefits and attorney fees. Gugin © 2009 Thomson Reuters/West. No Claim to Orig. US Gov. Works. http://web2.westlaw.com/print/printstream.aspx?prft=HTMLE&destination=atp&sv=Split&rs=WLW9.02... 3/13/2009 Page 5 of6 242 F.3d 374 242 F.3d 374, 2000 WL 1728303 (C.A.8 (Ark.» (Table, Text in WESTLAW), Unpublished Disposition (Cite as: 242 F.3d 374, 2000 WL 1728303 (C.A.8 (Ark.») Page 4 cross-appeals the district court's conclusion he was not entitled to coverage for his Timber Ridge stay. We affirm the award of medical benefits, but re mand to the district court for reconsideration of the attorney fees award. argues the district court wrongly considered materi al submitted by the parties, at the court's request, in determining the proper award. We disagree. The Plan had suggested partial hospitalization or skilled nursing care in lieu of treatment at Timber Ridge. Further, the Plan presented no evidence showing [I ][2][3] Because the Plan gave the administrator-Aet Gugin would not have required the suggested al na, or the lC. Penney Board of Governors (Board), ternative care for at least as long as he incurred in an appeal-the exclusive right and discretion to in charges at Timber Ridge, and the district court terpret, to rule on Plan language, and to determine sought additional evidence only to deterinine the coverage, the district court properly reviewed the cost of the alternative benefits the Plan had sugges decisions at issue for abuse of discretion. See Bird ted it would provide-not to determine the reason sell v. United Parcel Servo of Am., Inc., 94 F.3d ableness of the denial of the requested coverage. Cf 1130, 1133 (8th Cir. I996). We review the district Mansker v. TMG Life Ins. Co., 54 F.3d 1322, 1328 (8th Cir.1995) (declining to adopt insurer's view court's determination de novo. See id.Like the dis trict court, we determine whether the Plan's de that, when plan administrator has discretionary au cisions were supported by substantial evidence, thority to decide issues concerning payment of be considering only the evidence that was before the nefits but fails to do so because coverage is being administrator. See Farley v. Arkansas Blue Cross denied, courts may not independently decide issues and Blue Shield, 147 F.3d 774, 777 (8th Cir.1998). after determining benefits were improperly denied). We must affirm if " 'a reasonable person could Likewise, we disagree with Gugin that remand to have reached a similar decision, given the evidence Aetna to determine the cost of alternative benefits was required. before him, not that a reasonable person would have reached that decision." , See Sahulka v. Lu *2 [7][8][9] Finally, the Plan argues the court failed cent Tech., Inc., 206 F.3d 763, 769 (8th Cir.2000) (citation and emphasis omitted). to apply the relevant factors in awarding attorney fees, and the amount was unreasonable given Gu [4][5] The Plan argues the district court did not ap gin's limited success. We review the award of attor ply this deferential standard of review in consider ney fees in an ERISA case for abuse of discretion. See Dodson v. Woodmen of the World Life Ins. Co., ing as timely the administrative appeal the Plan ad ministrator had rejected as untimely. Our review of 109 F.3d 436, 440 (8th Cir.1997). In deciding the court's thorough order, however, convinces us whether to award attorney fees, the district court the court properly reviewed for an abuse of discre should consider the opposing party's culpability or tion, and we agree with the court it was unreason bad faith, its ability to pay, the deterrent effect an able for the Plan administrator not to extend the ap award would have on others, whether the requesting peal deadline in the circumstances of this case. We party sought to benefit all participants or to resolve also agree with the district court that the Plan's a significant ERISA legal question, and the relative denial of hospitalization costs was unreasonable but merits of the parties' positions. See id.Although the the Timber Ridge denial was reasonable. amount of the recovery is relevant, see Griffin v. Jim Jamison, Inc., 188 F.3d 996, 997 (8th [6] The Plan contends the district court was pre Cir.1999), the district court mentioned only that cluded from awarding Gugin the charges he would factor, see id. at 997-98 (it is unnecessary for the have incurred for care in a less medically intense district court to examine explicitly and exhaustively setting for the period of time he was hospitalized at all factors relevant to fee award, but where court Timber Ridge once it upheld the Plan's refusal to mentioned only amount of recovery, other factors provide coverage for Timber Ridge. The Plan also © 2009 Thomson Reuters/West. No Claim to Orig. US Gov. Works. http://web2.westlaw.com/printlprintstream.aspx?prft=HTMLE&destination=atp&sv=Split&rs=WLW9.02... 3/13/2009 Page 60f6 242 F.3d 374 242 F.3d 374, 2000 WL 1728303 (C.A.8 (Ark.» (Table, Text in WESTLAW), Unpublished Disposition (Cite as: 242 F.3d 374,2000 WL 1728303 (C.A.8 (Ark.») Page 5 deserved explicit consideration). We thus find the district court abused its discretion in awarding at torney fees without consideration of the additional factors. Accordingly, we affirm the district court's award of medical benefits, we vacate the award of attorney fees, and we remand for further proceedings con sistent with this opinion. C.A.8 (Ark.),2000. Gugin v. J.C. Penney Co., Inc. 242 F.3d 374, 2000 WL 1728303 (C.A.8 (Ark.» END OF DOCUMENT © 2009 Thomson Reuters/West. No Claim to Orig. US Gov. Works. http://web2.westlaw.com/print/printstream.aspx?prft=HTMLE&destination=atp&sv=Split&rs=WLW9.02... 3/13/2009
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