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Hirsh v. Boeing Health and Welfare Benefit Plan

June 14, 2010

JOEL E. HIRSH
v.
BOEING HEALTH AND WELFARE BENEFIT PLAN, A/K/A THE BOEING TRADITIONAL MEDICAL PLAN, AND BOEING EMPLOYEE BENEFITS PLAN COMMITTEE



The opinion of the court was delivered by: Joyner, J.

MEMORANDUM AND ORDER

This action is now pending before this Court for resolution of the parties' cross-motions for summary judgment. For the reasons outlined in the paragraphs which follow, the motions shall be granted in part and denied in part.

Background Facts

Plaintiff Joel Hirsh is an employee of the Boeing Company and, as such, he and his family have health care coverage under the Boeing Health and Welfare Plan, otherwise known as the Boeing Traditional Medical Plan (hereinafter "Plan"). Since he was a small child, Mr. Hirsh's son A.H. has required psychiatric and/or mental health treatment.*fn1 In 2006 when he was 15 years old, A.H. began receiving that treatment on an inpatient basis, at a number of different facilities.*fn2

On or about March 7, 2007, A.H. entered in-patient treatment at Innercept Academy, located in Coer D'Alene, Idaho. With the exception of several brief visits home to Wynnewood,Pennsylvania, A.H. remained at Innercept until April 19, 2008, when his parents transferred him to the King George School ("KGS"), a therapeutic boarding school in Vermont. A.H. apparently received in-patient treatment at the King George School until sometime in April 2009.

Despite Plaintiff's repeated submissions of bills and doctor's reports, and appeals for payment of A.H.'s in-patient expenses from Innercept and KGS, the defendants have refused coverage and/or reimbursement for any of A.H.'s treatment at KGS and have refused to pay anything more than $13,753 for the care which he received at Innercept.*fn3

On July 13, 2009, Plaintiff commenced this lawsuit pursuant to Section 502 of the Employee Retirement Income Security Act, 29 U.S.C. §1132 ("ERISA") seeking to recover the full amount of benefits due under the Plan, together with counsel fees, interest, and costs of suit. In reliance on the administrative record, both parties now move for the entry of judgment in their favor pursuant to Fed. R. Civ. P. 56.

Standards Governing Summary Judgment Motions

Fed. R. Civ. P. 56(c)(2) dictates the general standard for determining motions for summary judgment:

"The judgment sought should be rendered if the pleadings,the discovery and disclosure materials on file, and any affidavits show that there is no genuine issue as to any material fact and that the movant is entitled to judgment as a matter of law." An issue is genuine only if there is a sufficient evidentiary basis on which a reasonable jury could find for the non-moving party, and a factual dispute is material only if it might affect the outcome of the suit under governing law. Kaucher v. County of Bucks, 456 F.3d 418, 423 (3d Cir. 2006), citing Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248, 106 S. Ct. 2505, 91 L. Ed. 2d 202 (1986). The summary judgment standard requires us to resolve all ambiguities and to view all facts and draw all factual inferences in favor of the non-moving party. Celotex Corp. v. Catrett, 477 U.S. 317, 322, 106 S. Ct. 2548, 91 L. Ed. 2d 265 (1986); Gardner v. Unum Life Insurance Co. of America, 354 Fed. Appx. 642, 648, 2009 U.S. App. LEXIS 26363 at *14 (3d Cir. Dec. 4, 2009); Lawrence v. City of Philadelphia, 527 F. 3d 299, 310 (3d Cir. 2008). Under Fed. R. Civ. P. 56(a) and (b), a summary judgment motion may be filed by either the party claiming relief or the defending party and the same principles apply when there are cross-motions for summary judgment. See, Lawrence, supra.

Discussion

Congress enacted ERISA to "protect ... the interests of participants in employee benefit plans and their beneficiaries" by setting out substantive regulatory requirements for employee benefit plans*fn4 and to "provide for appropriate remedies, sanctions and ready access to the Federal courts." Aetna Health, Inc. v. Davila, 542 U.S. 200, 208, 124 S. Ct. 2488, 2495, 159 L. Ed. 2d 312 (2004) quoting 29 U.S.C. §1001. The purpose of ERISA is to provide a uniform regulatory regime over employee benefit plans.

Id.

ERISA "permits a person denied benefits under an employee benefit plan to challenge that denial in federal court." Barinova v. ING, No. 08-4189, 2010 U.S. App. LEXIS 2368 at *7 (3d Cir. Feb. 4, 2010), quoting Metropolitan Life Insurance Co. v. Glenn, 554 U.S. 105, 128 S. Ct. 2343, 2346, 171 L. Ed. 2d 299, 305 (2008). To this end, Section 502(a)(1)(B) provides the following, in relevant part:

(a) Persons empowered to bring a ...


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