Spizman v. BCBSM, Inc., No. 16-1557 (8th Cir. 2017)
Annotate this CaseThe Eighth Circuit affirmed the dismissal of plaintiff's claims against Blue Cross in a suit filed under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., after Blue Cross denied round-the-clock in-home health coverage. The district court properly dismissed Count I and II, because these claims for round-the-clock in-home nursing services were contrary to the plain meaning of the private-duty nursing exclusions in the 2012 and 2013 policies. The district court properly dismissed Count VI because the policy plainly excluded extended hours skilled nursing care, and plaintiffs may not use an estoppel theory to enlarge benefits under a written plan.
Court Description: Loken, Author, with Murphy and Kelly, Circuit Judges] Civil case - ERISA. Plaintiffs' claim for round-the-clock in-home nursing care fell within the plain meaning and common understanding of the "private-duty nursing" exclusion in the plaintiffs' 2012 policy; the Plan Administrator's decision that round-the-clock nursing was excluded from the 2013 policy was not an unreasonable interpretation of the plan; with respect to plaintiffs' claim that defendant's agents' representations regarding coverage estopped defendant from denying the claim, plaintiffs cannot use an estoppel theory to enlarge their benefits under a written plan.
Some case metadata and case summaries were written with the help of AI, which can produce inaccuracies. You should read the full case before relying on it for legal research purposes.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.