United States District Court, W.D. New York
For Karl Niedermaier, Plaintiff: Laurie A. Giordano, LEAD ATTORNEY, Leclair Korona Giordano Cole LLP, Rochester, NY.
For Southern Tier Building Trades Benefit Plan, Joint Board of Trustees of the Southern Tier Building Trades Benefit Plan, Defendants: Erin W. Smith, Margaret A. Clemens, LEAD ATTORNEYS, Hanok Mathew George, Littler Mendelson, P.C., Rochester, NY.
DECISION AND ORDER
ELIZABETH A. WOLFORD, United States District Judge.
Plaintiff Karl Niedermaier (" Plaintiff" ) is a natural gas pipeline superintendent
who is eligible for health benefits coverage under the Southern Tier Building Trades Plan (the " Plan" ). Plaintiff has a long history of bilateral hearing loss. In 2011, he received a cochlear implant at the University of Rochester Medical Center (" URMC" ). The Plan, through Defendant the Joint Board of Trustees of the Southern Tier Building Trades Benefit Plan (the " Board" ), denied his requests for coverage for his cochlear implant surgery, the cochlear implant device, and related treatment. Plaintiff appealed this decision twice; both his appeals were denied. Plaintiff commenced the instant action pursuant to the Employee Retirement Income Security Act (" ERISA" ), specifically 29 U.S.C. § 1132(a)(1)(B), seeking to recover benefits he claims were due to him under the Plan.
Both Plaintiff and Defendants have moved for summary judgment. (Dkt. 25, 26). Based on the record before the Court, the Board reasonably concluded that Plaintiff's cochlear implant expenses were not covered under the Plan due to the " artificial implant" exclusion. As a result, Plaintiff's motion for summary judgment is denied and Defendants' motion for summary judgment is granted.
Plaintiff is a member of the Laborer's International Union of North America 621 and is eligible for health benefits coverage through the Plan. (Dkt. 26-5 at ¶ 2; Dkt. 28-3 at 1). Plaintiff has suffered from serious hearing loss since birth. As of 2010, even high powered hearing aids were unable to provide him with adequate access to sound. (Dkt. 26-5 at ¶ 3). In 2011, his physician, Dr. John Wayman, and his audiologist determined that Plaintiff would be a good candidate for a cochlear implant. ( Id. at ¶ 4). A cochlear implant is a small electronic device that " can help provide a sense of sound to a person who is profoundly deaf or severely hard-of-hearing. The implant consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin. . . ." (Dkt. 26-1, Ex. A; Dkt. 28-3 at 3).
Jennifer Resch, a secretary at University Otolaryngology Associates, states that she spoke to an individual named Cassandra who was employed by the Plan on or about April 26, 2011, and was told that placement of the cochlear implant would be covered and that no precertification was necessary. (Dkt. 26-8 at ¶ 3). Defendants dispute this and state that on February 18, 2011, Plaintiff's wife called the Plan office to ask about coverage for hearing related claims and was told that hearing related claims were not covered; on March 20, 2011, the Plan rejected Plaintiff's claim for the cost of a comprehensive audiometry threshold evaluation on the basis that it was not covered; on May 31, 2011, Plaintiff's wife called the Plan office saying that Plaintiff needed hearing surgery, and on that same day, doctor's notes were faxed to the Plan office for consideration; on June 10, 2011, a representative from Strong Memorial Hospital's Financial Counseling Office, Mr. Monzzell, called the Plan office to ask questions about Plaintiff's case and was told that the surgery was not covered. (Dkt. 25-3 at ¶ 16).
On June 13, 2011, Dr. Wayman performed surgery on Plaintiff to place the internal portion of the cochlear implant. (Dkt. 26-5 at ¶ 6; Dkt. 28-3 at 5). On June 27, 2011, the Plan sent Plaintiff a letter denying his claim for the June 13, 2011, surgery. (Dkt. 26-5, Ex. B). The denial letter stated that the medical expenses related to the surgery were not covered because the Plan, in Section 3.10, contains exclusions for expenses related to: (1) " surgery, treatment and services for
artificial implants, except in connection with reconstructive surgery following a mastectomy" ; and (2) " 'hearing aids and hearing exams." ( Id.). The denial letter further informed Plaintiff that although the medical expenses related to his cochlear implant surgery were not covered under the insurance provisions of the Plan, they were reimbursable from Plaintiff's medical reimbursement account, up to the amount in the account. ( Id.).
On July 7, 2011, and July 8, 2011, URMC and University Otolaryngology Associates (" UOA" ) submitted letters to the Plan stating that they were appealing the denial of the claim on behalf of Plaintiff. (Dkt. 25-3 at ¶ 10). The July 7, 2011, letter was from audiologist Christy Hopson, Director of Clinical Services for URMC Audiology, who explained that a cochlear implant is not a hearing aid, and that it consists of two essential parts: " a surgically implanted internal device and an external sound processor that converts acoustic sound into electronic impulses transmitted through the skin to the internal device which then electrically stimulates the auditory nerve." (Dkt. 25-4 at 117). Ms. Hopson also included Plaintiff's audiology records. The July 8, 2011, letter from UOA also included medical records and a letter from Dr. Way man stating that the cochlear implantation was medically necessary for Plaintiff to continue to function in his job. ( Id. at 120-132). On July 15, 2011, an insurance collection specialist from URMC sent another letter to the Plan requesting that the letter be considered an official appeal of the denial of Plaintiff's claim. ( Id. at 134).
On August 19, 2011, the Plan (via Ellie Munson, the Fund Office Administrator) sent a letter to Plaintiff stating that they had received the letters from URMC and UOA and that they would consider the correspondence to be an appeal filed directly by Plaintiff. ( Id. at 137). The Plan's letter explained that the correspondence from URMC and UOA was primarily addressed to whether the surgery was medically necessary, and that Plaintiff's claim had not been denied on that basis. The August 19, 2011, letter further stated that " [t]he Board of Trustees believes that a cochlear implant is an 'implant' within the common meaning of that term (i.e. something that is placed, usually surgically, within a living body, such as a medical device). Furthermore, although a cochlear implant is not a traditional hearing aid, it is clearly a device implanted for the purpose of aiding a person to hear. . . ." ( Id. at 138).
On October 5, 2011, Plaintiff sent a letter to the Board and Ms. Munson labeled " Personal Appeal" in which he again requested that the Board reverse its decision. ( Id. at 141). Plaintiff questioned the Board's interpretation of " artificial implant," asking whether it would also extend to pacemakers and surgical screws and pins. Plaintiff explained that " [t]o [him], artificial implant implies images of breast implants, chin implants, and all that is cosmetic. The cochlear [implant] is simply implanted into my head closest to my ear and does not make me beautiful." ( Id.) Plaintiff also argued that the cochlear implant was not a hearing aid because " [y]ou cannot aide hearing if there is no hearing to begin with." ( Id.)
On October 26, 2011, Ms. Munson, on behalf of the Plan, sent a letter to Plaintiff denying his personal appeal. (Dkt. 25-4 at 143-45). The letter explained that even though the Plan allows only one internal appeal of a denied claim, the Board had considered his personal appeal because he never filed written confirmation that URMC and UOA were authorized to file an appeal on his behalf. ( Id. at 143). The letter further explained that although
Plaintiff claimed he had been led to believe his surgery would be covered, the Plan's records did not bear this out. ( Id. at 144). Finally, the letter explained that the Board had affirmed the denial of Plaintiff's claim for the reasons set forth in the August 19, 2011, letter. ( Id. at 145).
Plaintiff commenced the instant action on June 22, 2012. (Dkt. 1). Discovery closed on March 29, 2013. (Dkt. 22). The parties filed their competing motions for summary judgment on June 25, 2013. (Dkt. 25, 26). The parties filed their responses to each other's motions on July 26, 2013. (Dkt. 28, 29). Reply papers were filed on August 9, 2013, and August 12, 2013. (Dkt. 30, 31). The case was reassigned to the undersigned on February 21, 2014, without a decision having ...