Munro-Kienstra v. Health Care Service Corporation et al

Filing 50

OPINION MEMORANDUM AND ORDER IT IS HEREBY ORDERED that Defendants Motion for Summary Judgment, [Doc. No. 35], is granted. A separate judgment in accordance with this Opinion, Memorandum and Order is entered this same date. 35 Signed by District Judge Henry E. Autrey on 2/13/14. (CLA)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
DEBRA MUNRO-KIENSTRA,

)
)
Plaintiff,
)
)
v.
)
)
CARPENTERS’ HEALTH AND
)
WELFARE TRUST FUND OF ST. LOUIS, )
)
Defendant,
)

Case No. 4:12CV53 HEA

OPINION, MEMORANDUM AND ORDER
This matter is before the Court on Defendant’s Motion for Summary
Judgment, [Doc. No. 352], Plaintiff has filed a Motion for Summary Judgment,
[Doc. No. 40]. Because the Court concludes Defendant is entitled to judgment,
Plaintiff’s Motion is moot.
Facts and Background
Plaintiff seeks to recover health care benefits pursuant to Section 502(a) of
the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq.,
(ERISA), under the employee welfare benefit plan provided by Defendant.
Plaintiff alleges that Defendant wrongfully denied Plaintiff’s medical
benefit claims. Plaintiff’s claims were denied on December 10, 2008 and January
7, 2009. Plaintiff appealed the decision on June 2, 2009. Her appeals were

presented to the Appeals Committee for the Board of Trustees on July 16, 2009.
The denials were upheld on the basis that the procedure was experimental and
investigational and is excluded from coverage under the terms of the Plan. This
denial was communicated to Plaintiff on July 23, 2009.
The Plan document provides on page 55, under the heading “How to Appeal
a Denied Claim,” that any civil action under Section 502(a) of ERISA must be
filed within two (2) years of the date of the Trustees’ decision.
The Plan document provides on page 59, under the heading “Rules of
Construction”
The terms and provisions of this Plan shall be construed according to
the principles and in the priority as follows:
First, in accordance with the meaning under, and which will bring the
Plan into conformity with, the Internal Revenue Code and with
ERISA; and secondly, in accordance with the laws of the State of
Missouri.
The Plan shall be deemed to contain the provisions necessary to
comply with such laws.
This action was filed on January 11, 2012, almost two and one-half years
after the decision of the Appeals Committee was communicated to Plaintiff.
Plaintiff now seeks review of the denial.

-2-

Summary Judgment Standard
The standards for summary judgment are well settled. In determining
whether summary judgment should issue, the Court must view the facts and
inferences from the facts in the light most favorable to the nonmoving party.
Matsushita Elec. Indus. Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986);
Woods v. DaimlerChrysler Corp., 409 F.3d 984, 990 (8th Cir. 2005). The moving
party has the burden to establish both the absence of a genuine dispute of material
fact and that it is entitled to judgment as a matter of law. Fed.R.Civ.P. 56(c);
Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247 (1986); Celotex Corp. v.
Catrett, 477 U.S. 317, 322 (1986); Enter. Bank, 92 F.3d at 747. Once the moving
party has met this burden, the nonmoving party may not rest on the allegations in
his pleadings but by affidavit or other evidence must set forth specific facts
showing that a genuine issue of material fact exists. Fed.R.Civ.P. 56(e); Anderson
477 U.S. at 256; Krenik v. Le Sueur 47 F.3d 953, 957 (8th Cir. 1995). “‘Only
disputes over facts that might affect the outcome of the suit under the governing
law will properly preclude the entry of summary judgment.’ Anderson v. Liberty
Lobby, Inc., 477 U.S. 242, 248 (1986).” Hitt v. Harsco Corp., 356 F.3d 920, 923
(8th Cir. 2004). An issue of fact is genuine when “a reasonable jury could return a
verdict for the nonmoving party” on the question. Anderson, 477 U.S. at 248;
-3-

Woods v. DaimlerChrysler Corp., 409 F.3d at 990. To survive a motion for
summary judgment, the “nonmoving party must ‘substantiate his allegations with
sufficient probative evidence [that] would permit a finding in [his] favor based on
more than mere speculation, conjecture, or fantasy.’ Wilson v. Int’l Bus. Maces.
Corp., 62 F.3d 237, 241 (8th Cir. 1995)(quotation omitted).” Putman v. Unity
Health System, 348 F.3d 732, 733-34 (8th Cir. 2003). “[A] complete failure of
proof concerning an essential element of the nonmoving party’s case necessarily
renders all other facts immaterial.” Celotex, 477 U.S. at 323. The Court will
review the facts in this case with the stated standards in mind.
Discussion
Defendant is entitled to summary judgment because the two year contractual
limitation period in the insurance policy at issue bars Plaintiff’s claim for policy
benefits. The policy that Defendant issued is part of an employee welfare benefit
plan that is subject to the Employee Retirement Income Security Act of 1974
(ERISA),29 U.S.C. § 1001 et seq. 1 Under ERISA, a plan participant like Plaintiff
1

“The terms ‘employee welfare benefit plan’ and ‘welfare plan’ mean any
plan, fund, or program which was heretofore or is hereafter established or
maintained by an employer or by an employee organization, or by both, to the
extent that such plan, fund, or program was established or is maintained for the
purpose of providing for its participants or their beneficiaries, through the
purchase of insurance or otherwise ... disability ... benefits ...” 29 U.S.C. §
1002(1).
-4-

may bring a civil action under § 502(a)(1)(B) “to recover benefits due to [her]
under the terms of [her] plan, to enforce [her] rights under the terms of the plan, or
to clarify [her] rights to future benefits under the terms of the plan.” 29 U.S.C. §
1132(a)(1)(B).
“Statutes of limitations establish the period of time within which a claimant
must bring an action.” Heimeshoff v. Hartford Life & Acc. Ins. Co., 134 S.Ct. 604,
610 (2013). “ERISA § 502(a)(1)(B) does not specify a statute of limitations” for
filing suit. Id. Consequently, courts typically “borrow the most closely analogous
state limitations period.” Northlake Reg'l Med. Ctr. v. Waffle House Sys.
Employee Benefit Plan, 160 F.3d 1301, 1303 (11th Cir.1998).
Plaintiff asks the Court to apply the Missouri ten year statute of limitations,
MoRevStat. § 516.110(1), to her claim for policy benefits. The Court would
accept the invitation were it not for the fact that the two year time limit on lawsuits
under the express terms of the policy at issue overrides the statutory time limit.
As the Supreme Court recently reiterated in Heimeshoff, parties may provide
by contract for a limitations period that is shorter than the statutory period, and the
parties may select the date on which the contractual time limit begins to run.
Heimeshoff, 134 S.Ct. at 611. The rule dates to the Supreme Court's opinion in

-5-

Order of United Commercial Travelers of America v. Wolfe, 331 U.S. 586 (1947).
There, the Court held that, “in the absence of a controlling statute to the contrary, a
provision in a contract may validly limit, between the parties, the time for bringing
an action on such contract to a period less than that prescribed in the general
statute of limitations, provided that the shorter period itself shall be a reasonable
period.” Id. at 608. In Heimeshoff, the Supreme Court held that contractual time
limits on lawsuits are “especially appropriate when enforcing an ERISA plan.”
134 S.Ct. at 611–12. That is because,
“employers have large leeway to design disability and other welfare
plans as they see fit.” Black & Decker Disability Plan v. Nord, 538
U.S. 822, 833, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003) ... Th[e]
focus on the written terms of the plan is the linchpin of “a system that
is [not] so complex that administrative costs, or litigation expenses,
unduly discourage employers from offering [ERISA] plans in the first
place.” Varity Corp. v. Howe, 516 U.S. 489, 497, 116 S.Ct. 1065, 134
L.Ed.2d 130 (1996).
Id. at 612. Consequently, the Court “must give effect to the Plan's limitations
provision” unless the Court determines “either that the period is unreasonably
short, or that a ‘controlling statute’ prevents the limitations provision from taking
effect.” Id.
In considering the reasonableness factor, the Court again directs its attention
to Heimeshoff. The policy provides:

-6-

When requesting a review, the claimant or his/her authorized
representative should state the reason they believe the claim denial
was improper and submit any comments, documents, records or other
information which is considered appropriate. The Trustees will
consider all such submissions as part of the review. The claimant or
his/her authorized representative may have reasonable access to, and
copies of, all documents, records or other information relevant to the
claim upon request free of charge.
As required by law, the Board of Trustees' claim review will not give
deference to the original claim decision. If the original claim denial was the result
of a medical judgment, the Plan will consult with a healthcare professional who
has the appropriate training and experience to render an informed opinion. The
healthcare professional will not be the one used for the original claim
determination of his/her subordinate. Such individual or entity will be disclosed
upon written request to the Board of Trustees.
The Board of Trustees, as fiduciaries of the Plan, will generally make
a decision on the review within 45 days after receipt of the request for review,
unless special circumstances require an extension of time for processing in which
case a decision will be made as soon as possible, after receipt of the request for
review. If such an extension is required, a claimant or his/her authorized
representative will be notified within 45 days after receipt of the request for
review.
Notice of the Trustees' decision to deny the appeal in whole or in part
on the review will be in writing and will include the specific reasons for the
decision, as well as specific references to the pertinent Plan
provisions on which the decision is based and other information of
the types contained in the initial notice advising the member that the claim has
been denied. The decision of the Trustees is final. Any civil action under Section
502(a) of the Employee Retirement Income Security Act must be filed within two
years of the date of the Trustees' decision.
(Emphasis added).
The plan at issue in Heimeshoff stated: “‘Legal action cannot be taken
-7-

against The Hartford ... [more than] 3 years after the time written proof of loss is
required to be furnished according to the terms of the policy.’” Heimeshoff 134
S.Ct. at 609 (quoting policy).
The Supreme Court characterized the three year period as a “common
contractual limitations provision.” Heimeshoff, 134 S.Ct. at 610. Finding that the
three year period was reasonable even though the administrative review process in
Heimeshoff consumed nearly two years and left the plan participant with only one
year in which to file suit, the Court reasoned, “Heimeshoff does not dispute that a
hypothetical 1–year limitations period commencing at the conclusion of internal
review would be reasonable. Id. at 4. We cannot fault a limitations provision that
would leave the same amount of time in a case with an unusually long internal
review process while providing for a significantly longer period in most cases.” Id.
at 612–13. The Court added:
Heimeshoff, drawing on a study by the American Council of Life
Insurers of recent § 502(a)(1)(B) cases where timeliness was at issue,
states that exhaustion can take 15 to 16 months in a typical case.
Reply Brief 17–18, n. 3 (citing Brief for American Council of Life
Insurers et al. as Amici Curiae 29). In our view, that still leaves ample
time for filing suit.
Id. at 612, n.
Here, Plaintiff’s claims were denied on December 10, 2008 and January 7,

-8-

2009. Plaintiff appealed the decision on June 2, 2009. Her appeals were
presented to the Appeals Committee for the Board of Trustees on July 16, 2009.
The denials were upheld on the basis that the procedure was experimental and
investigational and is excluded form coverage under the terms of the Plan. This
denial was communicated to Plaintiff on July 23, 2009.
With respect to the second potential prohibition on a contractual time limit
on ERISA suits, namely a “controlling statute” that prevents the contractual
provision from taking effect, Plaintiff does not point to a statutory provision that
prohibits a plan from contracting to reduce the applicable statute of limitations.
The Supreme Court considered a variety of arguable statutory limitations in
Heimeshoff and found that none of them restricted a plan from contractually
establishing a time limit for lawsuits that is shorter than the statutory limit.
Heimeshoff 134 S.Ct. at 615–16.
Moreover, the Court has considered whether to toll the policy's time limit on
lawsuits because Defendant did not provide a copy of the policy to her with the
communication that her appeal was denied, so she may not have been aware of the
two year cutoff for litigation until after the time limit expired.
In Heimeshoff, the Supreme Court acknowledged that, “[i]f the
administrator’s conduct causes a participant to miss the deadline for judicial
-9-

review, waiver or estoppel may prevent the administrator from invoking the
[contractual] limitations provision as a defense.” Heimeshoff, 134 S.Ct. at 615.
Here, there is no basis for tolling because Plaintiff has not demonstrated that
Defendant’s conduct caused her to miss the two year deadline for judicial review.
Under 29 C.F.R. § 2560.503–1, an ERISA regulation, Defendant had to
advise Plaintiff of the two year limitation period in the letter in which Defendant
advised Plaintiff that it had completed an internal administrative review of her
claim for benefits. That regulation states that any written or electronic notification
of an adverse benefits determination must include “[a] description of the plan's
review procedures and the time limits applicable to such procedures, including a
statement of the claimant's right to bring a civil action under section 502(a) of
[ERISA] following an adverse benefit determination on review.” 29 C .F.R. §
2560.503–1(g)(iv). Defendant’s letter to Plaintiff fulfills the regulation’s
requirements. The letter provides:
[t]he decision of the Trustees is final. Under federal law the claimant
has a right to bring a civil action under Section 502(a) of the
Employee Retirement Income Security Act (“ERISA”) if the [sic]
dissatisfied with the decision of the trustees. Before bringing such an
action the claimant must exhaust the Plain’s claim and appeals
procedure. Any such action against the Plan under ERISA must be
filed within two years of the date on which the Trustees made their
decision on appeal. Any such action must be filed no more than three
years after the claim was due. The claimant further has the right to
- 10 -

receive free of charge upon written request all documents, records
and other information relevant to the claim. Such request should be
sent to the Fund office.
(Emphasis added).
Thus, the letter contains “a statement of the claimant’s right to bring a civil
action under section 502(a) of [ERISA].” More significantly, it specifically
contained the applicable limitation time period within which to commence her suit
for judicial review. The Court cannot, under Heimeshoff ignore the clear mandate
that the suit must have been commenced within two years from the time Plaintiff
was notified of the denial of the appeal.
Conclusion
For the reasons outlined above, summary judgment in favor of Defendant is
appropriate on Plaintiff’s ERISA claim.
Accordingly,
IT IS HEREBY ORDERED that Defendant’s Motion for Summary
Judgment, [Doc. No. 35], is granted.
A separate judgment in accordance with this Opinion, Memorandum and
Order is entered this same date.
Dated this 13th day of February, 2014.

_______________________________
HENRY EDWARD AUTREY
UNITED STATES DISTRICT JUDGE
- 11 -

- 12 -