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LIDOSHORE v. HEALTH FUND 917

February 23, 1998

SHARON LIDOSHORE, Plaintiff,
v.
HEALTH FUND 917, EMPIRE BLUE CROSS and BLUE SHIELD, sued herein as EMPIRE BLUE CHOICE, Defendants.



The opinion of the court was delivered by: BAER

 Hon. HAROLD BAER JR., District Judge:

 Defendant Health Fund 917 (the "Fund") moves for summary judgment on all five causes of action. Defendant Empire Blue Cross & Blue Shield ("Empire") moves for summary judgment on the first and fourth cause of action brought by the Plaintiff. The Plaintiff, proceeding pro se, cross-moves for summary judgment on all five causes of action. For the reasons discussed below, Empire's motion is GRANTED, the Fund's motion is GRANTED in part and DENIED in part, and the Plaintiff's motion is GRANTED in part and DENIED in part.

 I. Background

 The Plaintiff commenced this lawsuit pursuant to the Employee Retirement Income Security Act, as amended, 29 U.S.C. § 1001 et seq. ("ERISA"). Originally, the Plaintiff brought this action in New York County Civil Court in February 1997, attempting to collect a medical benefits claim. One month later, the Defendants removed the case to Federal District Court. Thereafter, the Plaintiff amended her complaint to allege that the Defendants also violated several of ERISA's procedural requirements.

 The Fund is a multi-employee welfare benefit plan administered jointly by labor and management trustees (the "Trustees"). Empire is a New York corporation engaged in the business of selling and administering group health insurance. Frank Lidoshore, the Plaintiff's husband, is employed by Interstate Poultry, an entity that contributes monthly to the Fund in order to secure medical benefits for its employees under a plan entitled Group 6HO. As a result of her marriage to Frank Lidoshore, the Plaintiff is a beneficiary of the Group 6HO plan. The Fund maintains and provides medical benefits for Group 6HO members and their beneficiaries through a contract with Empire.

 The gravamen of this dispute is based on a 1993 decision by the Trustees to follow the recommendation by their medical consultants that Group 6HO benefits should be reduced. This decision resulted in the elimination of coverage for well-baby care. Approximately two years later, in March 1995, the Plaintiff gave birth to a baby boy, Harrison, and incurred a medical bill totaling $ 1,099, resulting from Harrison's stay in the hospital nursery. Thereafter, the Plaintiff submitted this medical bill to Empire, which the Defendant declined to pay, contending that the Group 6HO plan did not cover routine nursery care.

  Following this denial, the Plaintiff sent a letter dated September 11, 1996 to Dr. DeCarvalho, an Empire employee, requesting a copy of the Group 6HO contract between the Fund and Empire. *fn1" Def.'s Ex. J. The Fund also received a copy of this letter. Additionally, in the letter to Dr. DeCarvalho, the Plaintiff appealed the denial of her claim. Empire, however, upheld the decision not to pay the medical bill in a letter dated October 23, 1996. In subsequent correspondence, the Fund explained the reasons for the denial of the Plaintiff's claim when responding to letters from Mr. and Mrs. Lidoshore.

 On these facts, the Plaintiff advances five causes of action: (1) against the Fund and Empire, alleging that the Defendants improperly declined to pay the Plaintiff's claim for routine nursery care; (2) against the Fund, for failure to provide an accurate summary plan description; (3) against the Fund, for failure to provide an important plan document following a written request; (4) against the Fund and Empire, for offering an inadequate explanation of the reasons for denying her claim, failing to appraise her of the appeal remedies available, and not providing a full and fair review; and (5) against the Fund, for failure to discharge its fiduciary duties. The Plaintiff also seeks costs and expenses.

 II. Discussion

 In a motion for summary judgment, the burden is on the moving party to establish that there are no genuine issues of material fact that prevent a judgment as a matter of law. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 256, 91 L. Ed. 2d 202, 106 S. Ct. 2505 (1986); Fed. R. Civ. P. 56(c). A dispute regarding a material fact is genuine "'if the evidence is such that a reasonable jury could return a verdict for the nonmoving party.'" Aldrich v. Randolph Cent. Sch. Dist., 963 F.2d 520, 523 (2d Cir.) (quoting Anderson, 477 U.S. at 248), cert. denied, 506 U.S. 965, 121 L. Ed. 2d 359, 113 S. Ct. 440 (1992). When determining how a reasonable jury would decide the issue, the court resolves all ambiguities and draws all inferences in favor of the nonmoving party. See Aldrich, 963 F.2d at 523.

 A. Denial of Benefit

 The Plaintiff alleges that the Defendants improperly declined to pay the medical expenses she incurred as a result of her newborn baby's routine stay in the hospital nursery. Consequently, the Court is called upon to determine the validity of the Plaintiff's benefit claim, pursuant to ERISA § 1132(a)(1)(B). A denial of benefits challenged under § 1132(a)(1)(B) is "reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115, 103 L. Ed. 2d 80, 109 S. Ct. 948 (1988). Where discretionary authority is provided the Court must review the challenge on an arbitrary and capricious standard. See O'Shea v. First Manhattan Co. Thrift Plan & Trust, 55 F.3d 109, 112 (2d Cir. 1995).

 Here, both the plan administrator, the Fund Trustees, and a plan fiduciary, Empire, were conferred discretionary authority. The Trust Agreement governing the establishment and administration of the Fund gives the Trustees the power "to enter into any and all contracts and agreements for carrying out the terms of this Agreement and Declaration of Trust and for the administration of the Welfare Fund and to do all acts as they, in their discretion may deem necessary or advisable, and such contracts and agreements and acts shall be binding and conclusive on the parties hereto and on the employees involved." Emmons Aff. P 18. Empire's discretionary authority is derived from its contract with the Fund, which provides that Empire "may develop or adopt standards which describe in more detail when [Empire] will or will not make payments . . . [and Empire] shall have all the powers necessary and appropriate . . . to construe this Contract [and] to determine all questions arising under this Contract . . . ." Def.'s ...


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