United States District Court, M.D. Pennsylvania
MALACHY E. MANNION, UNITED STATES DISTRICT JUDGE.
before the court are the defendant's motion for summary
judgment (Doc. 12) and the plaintiffs' motion for summary
judgment (Doc. 19). Based upon the court's review of the
record in this action, the defendant's motion will be
granted and the plaintiffs' motion will be denied.
plaintiffs filed this action pursuant to 29 U.S.C.
§1132(a) to recover benefits under an ERISA regulated
plan. In due course, the parties filed cross motions for
summary judgment. Summary judgment is appropriate “if
the pleadings, the discovery [including, depositions, answers
to interrogatories, and admissions on file] 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.” Fed.R.Civ.P.
56(c); see also Celotex Corp. v. Catrett, 477 U.S.
317, 322-23 (1986); Turner v. Schering-Plough Corp.,
901 F.2d 335, 340 (3d Cir. 1990). A factual dispute is
genuine if a reasonable jury could find for the non-moving
party, and is material if it will affect the outcome of the
trial under governing substantive law. Anderson v.
Liberty Lobby, Inc., 477 U.S. 242, 248 (1986); Aetna
Cas. & Sur. Co. v. Ericksen, 903 F.Supp. 836, 838
(M.D. Pa. 1995). At the summary judgment stage, “the
judge's function is not himself to weigh the evidence and
determine the truth of the matter but to determine whether
there is a genuine issue for trial.” Anderson,
477 U.S. at 249; see also Marino v. Indus. Crating
Co., 358 F.3d 241, 247 (3d Cir. 2004) (a court may not
weigh the evidence or make credibility determinations).
Rather, the court must consider all evidence and inferences
drawn therefrom in the light most favorable to the non-moving
party. Andreoli v. Gates, 482 F.3d 641, 647 (3d Cir.
prevail on summary judgment, the moving party must
affirmatively identify those portions of the record which
demonstrate the absence of a genuine issue of material fact.
Celotex, 477 U.S. at 323-24. The moving party can
discharge the burden by showing that “on all the
essential elements of its case on which it bears the burden
of proof at trial, no reasonable jury could find for the
non-moving party.” In re Bressman, 327 F.3d
229, 238 (3d Cir. 2003); see also Celotex, 477 U.S.
at 325. If the moving party meets this initial burden, the
non-moving party “must do more than simply show that
there is some metaphysical doubt as to material facts,
” but must show sufficient evidence to support a jury
verdict in its favor. Boyle v. County of Allegheny,
139 F.3d 386, 393 (3d Cir. 1998) (quoting Matsushita
Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574,
586 (1986)). However, if the non-moving party “fails to
make a showing sufficient to establish the existence of an
element essential to [the non-movant's] case, and on
which [the non-movant] will bear the burden of proof at
trial, ” Rule 56 mandates the entry of summary judgment
because such a failure “necessarily renders all other
facts immaterial.” Celotex Corp., 477 U.S. at
322-23; Jakimas v. Hoffmann-La Roche, Inc., 485 F.3d
770, 777 (3d Cir. 2007).
summary judgment standard does not change when the parties
have filed cross-motions for summary judgment. Appelmans
v. City of Phila., 826 F.2d 214, 216 (3d Cir. 1987).
When confronted with cross-motions for summary judgment, as
in this case, “the court must rule on each party's
motion on an individual and separate basis, determining, for
each side, whether a judgment may be entered in accordance
with the summary judgment standard.” Marciniak v.
Prudential Financial Ins. Co. of America, 184 Fed.Appx.
266, 270 (3d Cir. 2006) (citations omitted) (not
precedential). If review of cross-motions reveals no genuine
issue of material fact, then judgment may be entered in favor
of the party deserving of judgment in light of the law and
undisputed facts. Iberia Foods Corp. v. Romeo, 150
F.3d 298, 302 (3d Cir. 1998) (citation omitted). See
Nationwide Mut. Ins. Co. v. Roth, 2006 WL 3069721, at *3
(M.D. Pa. Oct. 26, 2006) aff'd, 252 Fed.Appx. 505 (3d
reviewing the parties' cross-motions for summary
judgment, the following facts are undisputed. The defendant
provided a Master Group Contract to Ronald Gillar's
employer, United Sporting Companies, which was effective
January 1, 2017 (“Contract”). Pursuant to the
Contract, Blue Cross administered the Plan of Benefits to
employees of United Sporting Companies (“Plan”).
The Plan provides coverage for medical benefits but in
Section IV specifically delineates a list of benefits that
are excluded from coverage under the Plan. One of these
specific exclusions from the Plan is:
INTOXICATION OR DRUG USE
Any service (other than Substance Use Disorder Services),
Medical Supplies, charges, or losses resulting from a Member
being Legally Intoxicated or under the influence of any drug
or other substance, or taking some action the purpose of
which is to create a euphoric state or alter consciousness.
The Member, or Member's representative, must provide any
available test results showing blood alcohol and/or
drug/substance levels upon request of the Corporation. If the
Member refuses to provide these results, no benefits will be
Plan defines “Legal Intoxication/Legally
Intoxicated” as occurring when “the Member's
blood alcohol level was at or in excess of the amount
established under applicable state law to create a
presumption and/or inference that the Member was under the
influence of alcohol, when measured by law enforcement or
the Plan provides that the employer, United Sporting
Companies, is charged with the administration of the Plan, as
indicated earlier, the Contract between United Sporting
Companies and Blue Cross provides that Blue Cross has the
final discretionary authority to determine whether plan
participants are eligible for benefits. Specifically, the
5. Corporation Authority.
As claims fiduciary, the Corporation shall have the final
discretionary authority to determine the eligibility for
Covered Expenses and to construe the terms of the Plan
represented by this Plan of Benefits. All decisions by the
Corporation in this regard are conclusive and binding, and
any judicial review of such a decision shall be conducted
under the arbitrary and capricious standard of review with
deference given to the Corporation's decision.
Gillar was a Member covered by the Plan. According to Mr.
Gillar's medical records, on or about June 9, 2017, he
was found unresponsive lying face down in the middle of a
road approximately 100 yards from an all-terrain vehicle
(“ATV”). Having suffered significant
injuries, the plaintiff was life-flighted to
Danville Medical Center (“Danville”). Records
show that the trauma transport reported a blood alcohol level
of 130 milligrams per deciliter as of 23:48 on June 9, 2017,
a level approximately 1.63 times the legal limit for a person
to be deemed intoxicated and materially and appreciably
impaired under either South Carolina law, as made
applicable by the Plan, or Pennsylvania law, where the
accident occurred. The plaintiff remained inpatient at
Danville for 22 days.
point in time, a claim for benefits was submitted to the
defendant on Mr. Gillar's behalf. According to a Notice
of Denial dated June 20, 2017, from Medical Management BCBSSC
to Geisinger Medical Center, Mr. Gillar's contract did
not cover his inpatient admission on June 10, 2017, because
of the intoxication exclusion discussed previously. It was
indicated that ...