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JAMES v. NEW YORK CITY DIST. COUNCIL OF CARPENTERS

December 13, 1996

REGINALD JAMES, Plaintiff, against NEW YORK CITY DISTRICT COUNCIL OF CARPENTERS' BENEFITS FUNDS, FREDERICK W. DEVINE, THOMAS NASTASI, JR., JOHN R. ABBATEMARCO, ROBERT J. CAVANAUGH, CHARLES TERGENSEN, JR., PAUL J. O'BRIEN, JOHN A. BRUNETTI and ALVIN M. JAFF, individually, and as TRUSTEES OF NEW YORK CITY DISTRICT COUNCIL OF CARPENTERS BENEFIT FUNDS and UNION LABOR LIFE INSURANCE COMPANY, Defendant.


The opinion of the court was delivered by: SPATT

MEMORANDUM OF DECISION AND ORDER

 SPATT, District Judge:

 This case arises from the claims of the plaintiff, Reginald James (the "plaintiff" or "James"), for the payment of health care benefits pursuant to the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1001 et seq., by the defendants, New York City District Council of Carpenters' Benefits Funds, Frederick W. Devine, Thomas Nastasi, Jr., John R. Abbatemarco, Robert J. Cavanaugh, Charles Tergensen, Jr., Paul J. O'Brien, John A. Brunetti and Alvin M. Jaff in their individual capacities and as trustees for the defendant benefit funds (the "defendants" or the "Funds"). According to the plaintiff, he is entitled to between $ 584,000 and $ 700,800 in benefit payments, depending upon which of James' pleadings or motion papers is referenced, plus statutory penalties, as a result of the health care costs he incurred between January 1, 1989 and December 31, 1992.

 Presently before the Court are the defendants' motion and the plaintiff's cross motion for summary judgment. The Court notes at the outset that this lawsuit was discontinued against the defendant Union Labor Life Insurance Company by stipulation dated January 18, 1996.

 I. Background

 The plaintiff, Reginald James, is a resident of Suffolk County and a member of the New York City District Council of Carpenters (the "Union"). As a Union member, James was a participant in Union's benefit plans which are administered by the defendant Funds. The individual defendants serve as the Funds' trustees.

 As of October 1, 1984, the Union maintained a welfare plan (the "Plan") providing for hospital and medical benefits to plan participants including the plaintiff. In order to explain the benefits provided, the defendants disseminated a summary plan description (the "SPD") to plan participants which James admits he received. See Affidavit of James Patterson, ("Patterson Aff.") Exh. C. The SPD expressly provides however, that it is not a substitute for the official insurance policies issued by the underlying carriers, namely Union Labor Life Insurance Company ("ULLICO") or Blue Cross/Blue Shield, which were available for review by all participants. SPD at 3. The plaintiff contends however, that although he made several attempts to review the Plan itself, his calls were either ignored or he was denied access.

 In addition to explaining coverage under the Plan, the SPD sets forth certain limitations. For example, the SPD provides that "Benefits for Covered Services are Available as Follows: . . . care rendered without prior hospitalization or through a non-participating Agency [is limited] to a maximum of 40 home care visits per year. In no event will coverage be provided for more that 200 visits in any calendar year." SPD at 19. Further, the SPD states that a participant is "covered" for charges by "a registered graduate nurse for private nursing services," SPD at 22, but excludes "expenses for: . . . which [the participant] would not be charged had there been no insurance; . . . [and for] which [the participant is] not required to pay." SPD at 23.

 Further limitations contained in the SPD provide that:

 
in general the benefits described in this booklet will not be paid or provided under the following circumstances:
 
-- If the treatment is not recommended or approved by a qualified physician;
 
-- If there is no charge for the services;
 
* * *

 SPD at 13. With respect to the provision of "Home Care," the SPD provides:

 
Home Care Benefits are available under a physician-approved plan of treatment when the necessary services are rendered through a non-profit New York State Certified Home Health Agency. Benefits will be provided only if hospitalization or confinement in a skilled nursing facility would otherwise have been required.

 SPD at 18-19.

 On September 5, 1986, the plaintiff's daughter Latisha R. James ("Latisha") was born. Since her birth, Latisha suffered numerous serious illnesses including meningitis, cardiac and respiratory failure, quadriplegia, and seizure disorder. She died on April 7, 1993 at age six. During her life, Latisha received health care, including administration of medical care from her mother, Christine Bartley James ("Christine"), a licensed practical nurse. Throughout this period, James submitted in excess of $ 300,000 in related medical claims other than services provided by his wife, all of which were paid by the defendants.

 According to James, he was told by defendant John Abbatemarco, the Union vice president and Fund trustee, and James Patterson, former manager of the Welfare Fund from 1991 to 1993 and now Deputy Director of the Fund, that his wife's services were covered by the Plan. James Dep. 268-69.

 In May 1993, after his daughter's death, James submitted a claim for payment based upon his wife's services, twelve hours per day, seven days a week for the period of January 1, 1989 through December 31, 1992, a period of four years. On May 27, 1993, this claim was denied. According to the Funds, Christine was not qualified as a home care provider under the Plan because she resided in the insured's home and was a member of the insured's immediate family. The plaintiff appealed this determination to the Fund's appeal committee which sustained the decision to deny benefits on July 14, 1993.

 In September 1993, James submitted a second claim seeking payment for his wife's medical services for sixteen hours per day, seven days per week during the same four year period. This claim was also denied but James did not appeal.

 On November 19, 1993, the plaintiff, then represented by counsel, filed his Complaint in this Court alleging multiple causes of action pursuant to ERISA, 29 U.S.C. §§ 1001 et seq. Subsequently, on March 6, 1995 the plaintiff, then appearing pro se, filed an Amended Complaint. This revised pleading condensed the previously separated allegations into a single multifaceted claim. However, because the Court does not wish to hold James hostage to his lack of legal expertise, the Amended Complaint will be given a broad reading to allege the following causes of action: (1) failure to pay benefits as provided for under the welfare plan in violation of 29 U.S.C. §§ 186 and 1132; (2) breach of fiduciary duty pursuant to 29 U.S.C. §§ 1104(a)(1) and 1106(b); and (3) failure to disclose required plan information pursuant to 29 U.S.C. § 1022.

 The defendants move for summary judgment in their favor pursuant to Fed. R. Civ. P. 56 dismissing the Amended Complaint arguing that under the relevant terms of the Plan and SPD, James was not entitled to any benefits. The plaintiff, represented by new counsel, opposes the motion arguing that he has sufficiently established his claims and cross moves for summary judgment in his favor contending that the defendants are liable for monetary damages because:

 
the Fund, by its operators, administrators and trustees:
 
i distributed an incomplete and/or inaccurate . . . SPD,
 
ii misrepresented material information regarding plaintiff's entitlement to nursing benefits under the employee welfare benefit plan; or in the alternative,
 
iii failed to properly advise the plaintiff as to his status and options under the employee welfare benefit plan,
 
iv failed to disclose documents to which the plaintiff was legally entitled,
 
v failed to give the plaintiff's claims a fair and proper review,
 
vi failed to give the plaintiff's claims a fair and proper appeal,

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