IN THE UNITED STATES COURT OF APPEALS
FOR THE FIFTH CIRCUIT
_____________________
No. 97-30452
Summary Calendar
_____________________
ANNIE DOWDEN, also known as
Annie J. Dowden,
Plaintiff-Appellant,
versus
BLUE CROSS & BLUE SHIELD OF
TEXAS, INC.,
Defendant-Appellee.
_______________________________________________________
Appeal from the United States District Court for
the Western District of Texas
(95-CV-1570)
_______________________________________________________
September 19, 1997
Before REAVLEY, JOLLY and HIGGINBOTHAM, Circuit Judges.
PER CURIAM:*
Appellant Annie Dowden (Dowden) brought suit against Appellee
Blue Cross & Blue Shield of Texas, Inc. (Blue Cross) for an alleged
breach of a policy obligation to pay benefits for expenses incurred
in treatment for silicone breast implant complications. Dowden
complains on appeal that the district court erred in granting
*
Pursuant to 5TH CIR. R. 47.5, the Court has determined that
this opinion should not be published and is not precedent except
under the limited circumstances set forth in 5TH CIR. R. 47.5.4.
summary judgment against her, holding that the Employment
Retirement Income Security Act (ERISA), § 29 U.S.C. 1132 (a)(1)(B)
governs the facts in this case, and that Blue Cross rationally
determined that the medical expenses which Dowden incurred were not
medically necessary, and therefore, not covered under the insurance
policy. We affirm.
I. JURISDICTION
The district court properly exercised subject matter
jurisdiction pursuant to 28 U.S.C. § 1441(b). A defendant may
remove a case on grounds that the plaintiff has asserted a claim
preempted by § 514(a) of ERISA. Metropolitan Life Ins. Co. v.
Taylor, 481 U.S. 58, 66 (1987). ERISA comprehensively regulates,
inter alia, employee benefit welfare plans that provide medical
care or benefits in the event of sickness through the purchase of
insurance. 29 U.S.C. § 1002(1); Pilot Life Ins. Co. v. Dedeaux,
481 U.S. 41, 45 (1987); Memorial Hosp. Sys. v. Northbrook Life
Ins. Co., 904 F.2d 236 (5th Cir. 1990).
ERISA’s preemption clause dictates that ERISA “shall
supersede any state causes of action insofar as they may now or
hereafter relate to any employee benefit plan.” 29 U.S.C. §
1144(a). The federal courts have broadly construed the
“deliberately expansive” language of the ERISA preemption clause.
Corcoran v. United Healthcare, Inc., 965 F.2d 1321, 1328-29 (5th
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Cir. 1992). A state cause of action relates to an employee
benefit plan whenever it has “a connection with or reference to
such a plan.” Hubbard v. Blue Cross & Blue Shield Ass’n, 42 F.3d
942, 945 (5th Cir. 1995)(quoting Corcoran, 965 F.2d at 1329). If
a state law claim addresses an area of exclusive federal concern,
such as the right to receive benefits under the terms of an ERISA
plan, then the claim falls in the province of the federal courts.
Hubbard, 42 F.3d at 945.
Dowden’s claim to recover medical expenses from Blue Cross
“relates to an employee benefit plan” thus falling within the
scope of ERISA’s preemption provision. “It is clear that ERISA
preempts a state law cause of action brought by an ERISA plan
participant or beneficiary alleging improper processing of a
claim for plan benefits.” Memorial Hosp., 904 F.2d at 245
(citing Pilot Life Ins. Co., 481 U.S. at 1553). Dowden was
insured under the group health insurance policy issued by her
former employer. She continued to participate in the Blue Cross
group policy even after she left her employment through the
provisions of the Consolidated Omnibus Budget Reconciliation Act
of 1985.
Dowden, as a former employee, comes under the rubric of
ERISA as a participant, 29 U.S.C. §1002 (7). She is able to
assert her claim pursuant to ERISA's civil enforcement provision,
29 U.S.C. § 1132(a)(1)(B). The Supreme Court has held that any
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suit falling within this provision, even if it purports to raise
only state law claims, is necessarily federal in character by
virtue of the clearly manifested intent of Congress.
Metropolitan Life, 481 U.S. at 62.
We agree with the district court that Dowden claims a
violation of ERISA when she alleges a denial of benefits due
under the Blue Cross policy. A federal question exists on her
claim and the district court’s exercise of jurisdiction was
proper. Hubbard, 42 F.3d at 945.
II. MEDICAL NECESSITY
Dowden’s theory of recovery and the summary judgment entered
against her rest upon whether Blue Cross as the plan
administrator abused its discretion in interpreting the term
“medically necessary” as expressly defined in the insurance
contract.
A denial of ERISA benefits by a plan administrator is
reviewed by the courts under a de novo standard unless the plan
gives the plan administrator “discretionary authority to
determine the eligibility for benefits or to construe the terms
of the plan.” Duhon v. Texaco, Inc., 15 F.3d 1302, 1305 (5th
Cir. 1994)(quoting Firestone Tire & Rubber Co. v. Bruch, 489 U.S.
101, 115 (1989)). Contrary to Dowden’s assertion, Southern Farm
Bureau Insurance Co. v. Moore, 993 F.2d 98 (1993), does not stand
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for the proposition that the court may look to general principles
of common law or state law absent ERISA guidance on the
interpretation of the plan. Moore states that because ERISA does
not dictate the appropriate standard of review for evaluating
benefit determinations of plan administrators, courts must first
look to the plan terms to determine if the plan administrator has
the discretionary authority to interpret the plan terms. 993
F.2d at 100.
The abuse of discretion standard is the appropriate standard
of review to challenges to a plan administrator’s interpretation
of the plan terms when that plan grants the administrator the
authority to make a final and conclusive determination of the
claim. Duhon, 15 F.3d at 1305 (citing Bruch, 489 U.S. at 115).
In applying the abuse of discretion standard, we analyze whether
the plan administrator acted arbitrarily or capriciously.
Bellaire Gen. Hosp. v. Blue Cross Blue Shield, 97 F.3d 822, 829
(5th Cir. 1996).
The district court correctly concluded that the contested
plan grants Blue Cross “the exclusive and conclusive authority to
determine coverage and benefits, and to interpret provisions of
the plan, including whether treatment is medically necessary.”
In pertinent part, the contract provides that “[t]he operation of
the plan requires decisions regarding eligibility and the
construction of terms. In executing this Contract, the Employer
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gives full and complete authority and discretion to the Carrier
to make decisions regarding eligibility and benefits under this
Contract. Such authority and discretion includes, but is not
limited to, determination whether services, care, treatment or
supplies are Medically Necessary . . . .” The contract also
delineates which services are medically necessary such as those
“essential to, consistent with and provided for the diagnosis or
the direct care and treatment of the condition, sickness,
disease, injury, or bodily malfunction,” as well as those
treatments “consistent with accepted standards of medical
practice.” Because the plan vests Blue Cross with such
authority, judicial review is limited to determining whether
substantial evidence exists in the record to support Blue Cross’s
decision that Dowden’s treatment was medically unnecessary or
whether its refusal to pay the submitted claim was arbitrary and
capricious. Bellaire Gen. Hospital, 97 F.3d at 828 (5th Cir.
1996). “An arbitrary decision is one made without a rational
connection between the known facts and the decision or between
the found facts and the evidence. Id., 97 F.3d at 828.
Dowden carries the burden of proving that Blue Cross
arbitrarily and capriciously concluded that the medical test and
treatments were medically unnecessary and therefore not covered
under the policy. Bayles v. Central States, Southeast, &
Southwest Areas Pension Fund, 602 F.2d 97, 99 (5th Cir. 1979).
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We agree with the district court’s finding that Dowden has not
satisfied her burden. Blue Cross evidences an established
procedure and policy for processing claims involving silicone
breast implant patients. Relying upon learned publications, Dr.
Benjamin V. Carnovale, along with other medical and legal staff
developed a written policy for the uniform processing of the
claims of silicone breast implant patients. Consistent with the
insurance contract, the policy also enumerates which procedures
are medically necessary. We agree with the district court’s
finding that Blue Cross demonstrated a reasonable basis in the
record in making its determination of non-coverage. Dr
Carnovale’s application of Blue Cross’s established policy and
his ensuing interpretation of medical necessity does not appear
to be arbitrary and capricious, inconsistent or evidence of a
lack of good faith.
Dowden contends that in lieu of the definition expressly
provided in the contract, medically necessary treatment should be
defined by “medical experts” with great weight given to the
opinion of the attending physician. No evidence in the record
exists nor does any legal authority stipulate that an attending
physician’s opinion should be granted more weight than the
established policies and procedures of the plan administrator.
To grant conclusive weight to the opinion of the attending
physician would vitiate the discretionary authority expressly
granted to Blue Cross in the contract.
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Dowden further argues that the trial judge was “absolutely
wrong and unjust” to defer to Dr. Carnovale’s determination that
the disputed claim was not medically necessary. Despite Dowden’s
contention, it is indeed proper for the district court to
exercise deference to the plan administrator’s interpretation
when the plan grants the plan administrator discretionary
authority to interpret the plan. Sunbeam-Oster Co. Group Ben.
Plan v. Whitehurst, 102 F.3d 1368, 1373 (5th Cir. 1997); Pierre
v. Connecticut Gen. Life Ins. co., 932 F.2d 1552, 1562 (5th
Cir.), cert. denied, 502 U.S. 973 (1991)(“Federal courts owe due
deference to an administrator’s factual conclusions that reflect
a reasonable and impartial judgment.”).
Finally, Dowden’s allegation, that Blue Cross did not
assert, in its answer, an affirmative defense that applies to the
district court’s decision, is without merit. Blue Cross
affirmatively asserted its defense that Dowden’s claims were not
covered by the ERISA plan and were not medically necessary within
the terms, condition and exclusions of the policy as legally
construed by the plan administrator. Further, there is no
requirement that Blue Cross rely on a fiduciary in order to fall
within the abuse of discretion standard governing the
interpretation the contract. Blue Cross may rely on its own plan
administrator to interpret the contract of insurance. Bruch, 489
U.S. at 115.
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We find no error in the district court’s holding that the
ERISA plan vests discretionary authority in Blue Cross to make
determinations as to the medical necessity of treatments, and
that Blue Cross did not abuse its discretion in refusing to pay
Dowden’s claims under Blue Cross’s interpretation of the plan
terms.
AFFIRMED.
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