Geddes v. United Staffing Alliance Employee Medical Plan

F I L E D
United States Court of Appeals
Tenth Circuit
PUBLISH
November 15, 2006
UNITED STATES CO URT O F APPEALS Elisabeth A. Shumaker
Clerk of Court
TENTH CIRCUIT

M ICHAEL GEDDES and KARI
GEDDES, individually and as parents
and guardians of ANDREW GED DES,
a minor child,

Plaintiffs-Appellees,
v. No. 05-4142
UNITED STAFFING A LLIANCE
EM PLO Y EE M ED IC AL PLA N;
U .S.A . U N ITED STA FFIN G
ALLIA NCE, L.L.C., a limited liability
company, and EV EREST
ADM INISTRATORS, INC., a Utah
corporation,

Defendants-Appellants.

A PPE AL FR OM T HE UNITED STATES DISTRICT COURT
FOR T HE DISTRICT OF UTAH
(D .C . NO. 2:03-CV-440-PGC)

D. David Lambert, (Leslie W . Slaugh, with him on the brief) How ard, Lewis &
Petersen, L.L.C., Provo, Utah, for Defendant-Appellant Everest Administrators,
Inc.

Lawrence D. Buhler, Salt Lake City Utah, for Defendant-Appellant United
Staffing Alliance, L.L.C.

Jeffrey J. Droubay (M ichael L. Larson with him on the briefs) Parsons Behle &
Latimer, Salt Lake City, Utah, for Plaintiffs-Appellees.
Before KELLY, HOL LOW A Y, and M cCO NNELL, Circuit Judges.

M cCO NNELL, Circuit Judge.

Since the Supreme Court’s decision in Firestone Tire and Rubber Co. v.

Bruch, 489 U.S. 101 (1989), federal courts have reviewed an ERISA health plan’s

denial of benefits for arbitrariness and capriciousness, so long as the plan

explicitly grants discretionary authority to an administrator or other fiduciary to

render benefit decisions. Now we are called upon to decide w hether a fiduciary’s

decision to delegate part of its Firestone authority to an independent claims

administrator triggers de novo review. W e hold that it does not.

I. Background

Andrew Geddes, a Utah teenager, badly damaged his spinal cord on a

church-sponsored excursion to Lake Powell in the summer of 2002. On June 27,

he dove into shallow water from the lake’s edge and resurfaced unable to move

his arms or legs. An air ambulance transported Andrew from Lake Powell to St.

M ary’s Hospital in Grand Junction, Colorado, where physicians determined he

had severely injured his neck and spinal column. He was placed in intensive care.

On July 1, 2002, Andrew underwent surgery to repair his spine. Following

the operation, Andrew remained in the intensive care unit with a halo device

screw ed to his skull to prevent his repaired spinal chord from slipping. He

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received nourishment intravenously until he left St. M ary’s for Primary

Children’s Hospital in Salt Lake City, Utah, on July 15, 2002.

Due to his fragile condition, Andrew ’s physicians at St. M ary’s

recommended he be transferred to Primary Children’s Hospital by helicopter. But

his parents’ health plan, United Staffing Alliance— Defendants here— denied

coverage for this mode of transport. Andrew was taken the five hours from Grand

Junction to Salt Lake City by ground ambulance, and once at Primary Children’s,

was admitted to the neuroscience ward.

For the next two months, Andrew received in-patient care at Primary

Children’s Hospital. He arrived still wearing the halo apparatus, catheterized,

attached to an intravenous drip, and with splints on his arms and both legs.

Andrew’s primary treating physician at Primary Children’s, Dr. Terese Such-

Neibar, diagnosed Andrew with a “C-4 asia class C spinal” injury complicated by

a urinary tract infection. She recommended two months of rehabilitation, bowel

and bladder treatment, medication for infectious disease, and pain control— a

regimen she stated was medically necessary and typical for patients in Andrew ’s

condition. Hospital personnel also provided Andrew with respiratory and

radiological treatment until his discharge on September 10, 2002.

The Geddeses depended for healthcare coverage on the United Staffing

Alliance Employee M edical Plan, in which they participated as a family through

M ichael Geddes’ employer, United Staffing Alliance. The United Staffing Plan

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(the “Plan”) is an employee welfare benefit plan as defined by the Employee

Retirement Income Security Act of 1974, “ERISA,” 29 U.S.C. §§ 1001–1461.

The Plan’s terms are defined in the M aster Plan Description. All parties agree the

Plan covered Andrew as a dependent at the time of his accident and subsequent

treatment. The Plan names Defendant United Staffing as both fiduciary and

administrator and provides that as the fiduciary, United Staffing will engage an

independent third party to review members’ claims and administer all benefits.

That third party is Everest Administrators, Inc., also a defendant here. Through

Everest, United Staffing contracted with a network of medical care providers to

offer services to plan participants at discounted contract prices. The Plan also

covers care given by out-of-network providers at the “usual and customary rate as

determined by the Plan.” Appellees’ App. at 263. Importantly, the Plan

explicitly reserves to United Staffing the right to make all final decisions about

benefits paid under its terms, as well as the authority to interpret disputed Plan

provisions.

At Everest Administrators’ direction, United Staffing ultimately covered

only $40,921 of Andrew’s $185,892 in medical bills. United paid less than half

of the cost of Andrew’s treatment at St. M ary’s Hospital on the ground that the

hospital’s charges exceeded the “usual and customary” rate covered by the Plan.

United denied almost all of Andrew ’s claims arising from his stay at Primary

Children’s Hospital in Salt Lake City as well, contending Andrew’s treatment

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there amounted to rehabilitation, for which the Plan imposed a $2,500 cap. In a

series of letters and phone calls exchanged with Everest and Intracorp, another

claims review agency employed by United Staffing, Andrew’s parents disputed

both United’s interpretation of “usual and customary” and its characterization of

their son’s treatment as “rehabilitative.” U nited Staffing insists the Plan gives it

wide discretion as Plan administrator and fiduciary to interpret the document’s

terms. And while Everest professed in a letter to the Geddeses’ attorney to

“completely agree that the rehabilitation care was medically necessary,” it stood

by its denial of benefits based on the terms of the Plan. The Geddeses filed suit

in federal district court, asserting that United Staffing’s denial of benefits was

improper under ERISA § 502(a)(1)(B) and (a)(3). They also alleged a breach of

fiduciary duty in violation of ERISA §§ 404(a) and 502(a)(3), and a violation of §

502(c)(1)(B) due to the Defendants’ failure to provide requested Plan documents.

Shortly thereafter, the parties filed cross motions for summary judgment.

The district court granted summary judgment in favor of the Geddeses on

their first cause of action. The court entered judgment for United Staffing and

Everest Administrators on claims two and three. United Staffing and Everest

Administrators appeal from the district court’s judgment in favor of the Geddeses.

They contend the district court applied the incorrect standard of review, relied on

extrinsic evidence beyond the administrative record, misinterpreted Plan

provisions, and failed to consider U nited Staffing’s pre-certification argument.

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Everest additionally claims that the district court’s money judgment against it was

clear legal error.

II. Discussion

A. Standard of Review for Benefit Determinations

The first and most significant issue we must decide is the standard to apply

in review ing United Staffing’s denial of health benefits. This question colors all

the rest. The district court concluded it had authority to review United’s

determinations de novo, rather than for arbitrariness and capriciousness. W e

disagree.

ERISA allows plaintiffs to sue in federal court to “recover benefits due . . .

under the [healthcare] plan, to enforce . . . rights under the terms of the plan, or to

clarify . . . rights to future benefits under the terms of the plan.” 29 U.S.C. §

1132(a)(1)(B). But the ERISA statute does not specify the judicial standard of

review. The Supreme Court closed the lacuna in 1989, holding in Firestone Tire

and Rubber Co. v. Bruch, 489 U.S. 101 (1989), that a denial of benefits

challenged under § 1132(a)(1)(B) “is to be reviewed under a de novo standard,

unless the benefit plan gives the administrator or fiduciary discretionary authority

to determine eligibility for benefits or to construe the terms of the plan.” Id. at

115. If the plan does explicitly confer discretionary authority on an administrator

with so-called Firestone language, courts must review benefit determinations

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under an “arbitrary and capricious” standard. Chambers v. Family Health Plan,

100 F.3d 818, 825 (10th Cir. 1996).

The U nited Plan contains Firestone language. The M aster Plan Description

provides: “The Company is the named fiduciary and is the plan administrator of

the Plan . . . . [T]he Company makes all final decisions about benefits paid from

the Plan.” Appellees’ App. at 250 (emphasis in original). Despite this provision,

the district court found that by delegating claims administration to Everest,

United Staffing failed to exercise its administrative discretion and thereby

forfeited its right to deferential review. The court relied for this conclusion on

our decision in Gilbertson v. Allied Signal Inc., 328 F.3d 625 (10th Cir. 2003), in

which we held that a plan administrator must actually exercise the discretion the

Firestone language confers in order to enjoy deferential review of its decisions.

Id. at 631-32. In Gilbertson, the plan administrator failed to render a decision on

a disability claim prior to the deadline, and the claim was accordingly “deemed

denied” pursuant to ERISA regulations. Id. at 631. This Court held that “when

substantial violations of ERISA deadlines result in the claim’s being

automatically denied on review , the district court must review the denial de novo,

even if the plan administrator has discretionary authority to decide claims.” Id.

W e reasoned that “[d]eference to the administrator’s expertise is inapplicable

where the administrator has failed to apply his expertise to a particular decision.”

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Id. at 632. “[A] ‘deemed denied’ decision is by operation of law rather than the

exercise of discretion.” Id. at 631.

The district court below held that United Staffing’s delegation of authority

to an independent claims agency similarly constitutes a failure to exercise

administrative discretion, triggering de novo review. Like many managed-care

providers, United devolves the administrative task of reviewing beneficiary

claims to an independent, non-fiduciary third party. The United Plan explicitly

anticipates this delegation: “The Company will engage an independent claims

administrator to administer the Plan, however, the Company makes all final

decisions about benefits paid from the Plan.” A ppellees’ A pp. at 250 (emphasis

in original).

The district court interpreted the ERISA statute to preclude judicial

deference if fiduciaries pursue this sort of delegation. On the court’s logic, the

party to which a plan fiduciary or administrator delegates the responsibility to

review claims must also be a fiduciary. If the administrator delegates

responsibility to a non-fiduciary, the court reasoned, the plan effectively has no

fiduciary exercising the sort of discretion that qualifies for Firestone deference.

Therefore, United Staffing may not both claim judicial deference and delegate

responsibility for claims administration to Everest, because Everest is an

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independent third party— that is, not itself a fiduciary under the Plan. 1 That

Everest, on behalf of United Staffing, handled every claim submitted by the

Geddeses led the district court to conclude that United Staffing effectively did

nothing, totally failing for purposes of the ERISA statute and Gilbertson to

exercise its discretion and thereby forfeiting its claim to deferential review.

W e cannot agree with this logic, w hich we suspect was at least partly

informed by the district court’s misleadingly truncated reading of a provision of

the ERISA statute. The district court quoted the statute to say: “The instrument

under which a plan is maintained may expressly provide for procedures . . . (B)

for named fiduciaries to carry out fiduciary responsibilities . . . under the plan.”

Appellees’ App. at 801. From this, the court drew the negative inference that the

Plan may not provide for non-fiduciaries to carry out fiduciary

responsibilities— at least not without forfeiting judicial deference to the decisions

made by the non-fiduciary. But the district court omitted a critical phrase from

the statute, w hich actually reads: “The instrument under w hich a plan is

maintained may expressly provide for procedures . . . (B) for named fiduciaries to

designate persons other than nam ed fiduciaries to carry out fiduciary

1
The district court found that Everest Administrators, Inc., was an
independent, third-party non-fiduciary. Appellees’ A pp. at 800. No party to this
action argues otherw ise, and we see no reason to revisit that conclusion. If
Everest did qualify as an ERISA fiduciary under 29 U.S.C. § 1002(16)(A), 21(A),
our conclusion that its benefits decisions on behalf of United Staffing are entitled
to deferential review would follow all the more readily.

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responsibilities . . . under the plan.” 29 U.S.C. § 1105(c)(1) (emphasis added).

The plain language of the statute thus endorses the delegation to non-fiduciary

third parties the district court found suspect.

Nor is the district court’s interpretation a valid extension of either

Firestone or this Court’s decision in Gilbertson. To qualify their decisions for

deferential review, Firestone requires only that ERISA health plan administrators

and fiduciaries reserve discretionary authority to themselves in the plan

document. 489 U.S. at 115. The Supreme Court arrived at this rule by relying on

the principles of trust law. Id. at 111 (“In determining the appropriate standard of

review for actions under § 1132(a)(1)(B), we are guided by principles of trust

law.”). Professor John Langbein has explained that “ER ISA is, in its most

important dimension, federal trust law. Substantively, the statute . . . absorbs the

core fiduciary duties of loyalty and prudence from trust law and extends them to

govern all aspects of plan administration.” John L. Langbein, What Erisa M eans

by “Equitable”: The Supreme Court’s Trail of Error in Russell, M ertens, and

Great-W est, 103 Colum. L. Rev. 1317, 1319 (2003). Trust doctrine teaches that if

a trustee has been endowed by the trust instrument with discretionary authority,

courts w ill not interfere with the trustee’s decisionmaking unless he acts

dishonestly or fails in his judgment. Restatement (Second) of Trusts § 187 cmt. e

(1959). Following this instruction, the Firestone Court declined to limit how an

ERISA plan administrator, vouchsafed discretion under the plan document, may

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exercise its discretionary authority. See 489 U.S. at 111. Specifically, Firestone

does not limit the parties to whom a fiduciary may delegate its authority, beyond

those limits implicit in the principles of trust law. Consequently, we turn to trust

law itself for further guidance.

Long-accepted trust doctrine holds that while a fiduciary may not delegate

the entire administration of his trust absent specific authorizing language in the

trust instrument, a fiduciary may delegate the performance of certain tasks “which

it is unreasonable to require him personally to perform.” Restatement (Second) of

Trusts § 171 cmt. d (1959). See, e.g., Wachovia Bank and Trust Co. v. M organ,

182 S.E.2d 356, 363 (N.C. 1971). Trust law regards this discretion to delegate as

inherent in the fiduciary-trustee. The fiduciary’s inherent discretion is confirmed

and extended when the authority to delegate is explicitly mentioned in the trust

instrument. “By the terms of the trust a trustee may be permitted to delegate to

agents or to co-trustees or to other persons the administration of the trust or the

performance of acts which could not otherwise be properly delegated.”

Restatem ent (Second) of Trusts § 171 cmt. j; see Central States v. Central

Transport, Inc., 472 U.S. 559, 568-69, 570-71 (1985).

Importantly for the disposition of the issue before us, trust law does not

require a fiduciary to delegate his authority only to other fiduciaries. Rather, the

trustee is at liberty to delegate administrative tasks to “agents” or “other persons”

as is necessary to carry out the purposes of the trust. Restatement (Second) of

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Trusts § 171 cmt. j; see also id. § 186 cmt. d; In re Butler’s Trusts, 26 N.W .2d

204, 211 (M inn. 1947); Hagedorn v. Arens, 150 A. 4, 8 (N .J. Ch. 1930). A

fiduciary’s decision to delegate does not violate his responsibility to the trust

beneficiary insofar as the fiduciary himself remains personally liable for any

decisions taken on his behalf. In sum, the fiduciary is responsible for actions

performed in his name. Restatement (Second) of Trusts § 225 (1959). The same

is true in the ERISA context.

Once a health plan administrator, the ERISA counterpart to trust law ’s

fiduciary-trustee, has been delegated discretionary authority under the terms of

the ERISA plan, nothing prevents that administrator from then delegating portions

of its discretionary authority to non-fiduciary third parties, as any similarly-

situated trustee may do. This is especially true when such delegation is explicitly

authorized by the plan document. The plan administrator remains liable,

however, for decisions rendered by its agents, just as a trustee remains ultimately

responsible for the actions of his delegates. In the instant case, the Plan

specifically empow ered its fiduciary, United Staffing, to employ an independent

third party to review benefit claims, even while reserving to United Staffing final

authority over all benefit determinations. United Staffing’s decision to delegate

limited authority to Everest Administrators according to the terms of the

controlling Plan instrument accords with Firestone and with the background

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principles of trust law. It does not constitute a failure of fiduciary judgment

sufficient to warrant de novo review.

The district court justified its contrary conclusion by citing to our decision

in Gilbertson, but its reliance on that case is misplaced for two reasons. First,

Gilbertson’s core holding finds no application here. Gilbertson stands for the

proposition that ERISA administrators are not entitled to deference for “deemed

denied” decisions made “by operation of law rather than the exercise of

discretion.” 328 F.3d at 631. But Everest and United did not simply deem the

Geddeses’ claims “denied” without further review, as the defendant-administrator

did in Gilbertson. Id. Instead, Everest made a benefits determination according

to the procedures of the Plan, which United, as the Plan fiduciary, then accepted.

Thus, unlike in Gilbertson, discretion was exercised by some combination of the

fiduciary and its agent.

Gilbertson in no way implies, as the district court inferred, that plan

fiduciaries qualify for Firestone deference only if they delegate their authority to

other named fiduciaries. In fact, we approved in Gilbertson a plan

administrator’s delegation of claims review authority to an independent, third-

party claims agency as an appropriate exercise of fiduciary discretion. 328 F.3d

at 630. The facts are closely analogous to the situation here. The health plan

administrator in Gilbertson, AlliedSignal, named a third party claims

administrator, Life Insurance Company of North America, to administer its plan

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and determine eligibility benefits. Id. at 628. W e found no fault with this

procedure: “A llied Signal’s plan expressly vests discretionary authority to

determine benefits eligibility in the Plan Administrator [], who has delegated its

discretion to LINA. . . . Therefore, because the Plan, albeit indirectly, grants

discretionary authority to LINA, LINA’s decisions on benefit claims should

generally be reviewed under the arbitrary and capricious standard.” Id. at 630.

W e follow that analysis in the present case.

Although the G eddeses refer us to no cases adopting a contrary

interpretation, we are aware of at least one circuit that disagrees with our

conclusion. In Baker v. Big Star Div. of the Grand Union Co., 893 F.2d 288 (11th

Cir. 1990), the Eleventh Circuit held that in order to qualify for Firestone

deference, an ERISA plan administrator that delegates its authority must do so

only to other fiduciaries. Id. at 291. The Eleventh Circuit’s logic parallels the

district court’s in our case. “[A]ny entity or person found not to be an ERISA

‘fiduciary’ cannot be an ‘administrator with discretionary authority’ subject to the

arbitrary and capricious standard.” Id. 2 W hile we agree that an ERISA plan

2
The Ninth Circuit’s position regarding the power of named fiduciaries to
delegate their authority is ambiguous. In M adden v. ITT Long Term Disability
Plan for Salaried Em ployees, 914 F.2d 1279 (9th Cir. 1990), the Ninth Circuit
held that “where (1) the ERISA plan expressly gives the administrator or
fiduciary discretionary authority to determine eligibility for benefits or to
construe the terms of the plan and (2) pursuant to ERISA . . . a named fiduciary
properly designates another fiduciary, delegating its discretionary authority, the
‘arbitrary and capricious’ standard of review . . . applies to the designated
(continued...)

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administrator must be a fiduciary, 29 U.S.C. § 1002(16)(A ), 21(A), there is

nothing in the language of the ERISA statute, the logic of Firestone, or the

background principles of trust law that requires fiduciaries, when delegating

authority, to delegate only to other fiduciaries. Indeed, we would go so far as to

say the plain language of the ERISA statute and the venerable body of trust law

say just the opposite. Decisions made by an independent, non-fiduciary third

party at the behest of the fiduciary plan administrator are entitled to Firestone

deference because the third parties act only as agents of the fiduciary. For

purposes of liability, decisions made by third parties are decisions made by the

fiduciary. If a plan administrator has been allotted discretionary authority in the

plan document, the decisions of both it and its agents are entitled to judicial

deference. 3

It remains now to apply this standard to the disputed claims denials in this

case.

2
(...continued)
ERISA -fiduciary as well as to the named fiduciary.” Id. at 1283-84 (internal
citations omitted). This might be read to require that fiduciaries delegate their
authority only to other fiduciaries in order to qualify for Firestone deference, but
such an interpretation is not necessary and would, in any event, be dictum.
3
Contrary to the dissent, it is immaterial for present purposes whether
Everest’s responsibilities are labeled “ministerial” or “discretionary.” Either way,
all decisions were made by United Staffing or by its agent – unlike Gilbertson,
where the decision was made by operation of law, due to the failure of the
fiduciary or its agent to make the relevant decision before the deadline.

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 B. The Primary Children’s Claims

United Staffing declined to cover the majority of the Geddeses’ medical

costs from both Primary Children’s Hospital in Salt Lake City and St. M ary’s

Hospital in Grand Junction, but for different reasons. W ith regard to the denial of

coverage for Andrew Geddes’s treatment at Primary Children’s, United concluded

that the care provided there was almost entirely rehabilitative in nature. As part

of its evaluation of that rationale for denying benefits, the district court

supplemented the administrative record with the affidavit of Dr. Teresa Such-

Neibar and with evidence from deposition testimony. Appellees’ App. at 795,

805, 806, 814. But a reviewing court is permitted to consider extrinsic evidence

only on de novo review of a benefit claim. Hall v. Unum Life Ins. Co. of Am., 300

F.3d 1197, 1202 (10th Cir. 2002) (holding courts may “supplement [the

administrative] record when circumstances clearly establish that additional

evidence is necessary to conduct an adequate de novo review of the benefit

decision”). The district court’s review should not have been de novo.

Consequently, we direct the district court on remand to consider only evidence

from the closed administrative record. In so doing, we imply no opinion as to the

outcome the district court should reach under the arbitrary and capricious

standard.

United Staffing also appeals from the district court’s rejection of its claim

that because the Geddeses failed to pre-certify Andrew’s in-patient care at

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Primary Children’s, United’s denial of benefits was justified. The district court

refused to consider this argument on summary judgment, finding United had

failed to raise the claim at the proper time. Our case law forbids the district court

from relying on new arguments or materials to decide a summary judgment

motion unless the opposing party is provided an opportunity to respond. Beaird

v. Seagate Tech., Inc., 145 F.3d 1159, 1165 (10th Cir. 1998). W hether to allow

supplemental briefing on a newly-raised issue is a “supervision of litigation”

question we review for abuse of discretion. See Pippin v. Burlington Res. Oil &

Gas, 440 F.3d 1186, 1192 (10th Cir. 2006); Beaird, 145 F.3d at 1164-65. W e

affirm the district court.

United Staffing contends it raised the pre-certification argument in its

briefs before the district court, in its initial answ er to Plaintiff G eddeses’

complaint, and in its memorandum of opposition to the Geddeses’ summary

judgment motion. Upon review of the record, we find no mention of the pre-

certification argument in any of these places. United raised the issue at oral

argument before the district court on December 8, 2004, and again in

supplemental briefing to the court on February 11, 2005. Contrary to U nited’s

assertions, however, its initial answer to the Geddeses’ complaint mentions

nothing about pre-certification, but claims only that the Plan’s denial of benefits

was not arbitrary and capricious. Appellants’ App. at 28-29. Similarly, United’s

memorandum in opposition to the Geddeses’ motion for summary judgment

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quotes portions of correspondence between the Geddeses and Defendant Everest,

including internal notations made by Everest that identify pre-certification as a

problem. But United did not make an affirmative pre-certification argument at

this stage either. Instead, the quotations are adduced in support of United’s claim

that it engaged in “meaningful dialogue” with the Geddeses. In effect, United

seeks to bootstrap the pre-certification argument into the broader issue of its

discretion as administrator under the Plan, though it failed to argue the pre-

certification issue explicitly. The court did not abuse its discretion by refusing to

consider the new issue at the late juncture when it w as raised. Beaird, 145 F.3d

at 1164-65.

In sum, we reverse the district court’s judgment as to the Primary

Children’s claims and remand for reconsideration on the administrative record,

according to an “arbitrary and capricious” standard of review. W e affirm the

district court’s refusal to consider U nited’s belated pre-certification claims.

C. The St. M ary’s Claims

United Staffing refused to pay more than $37,363.33 of the Geddeses’

$86,460.70 in bills from St. M ary’s Hospital in Grand Junction, on the ground

that the hospital’s charges exceeded the “usual and customary” fee United

Staffing agreed to cover in the Plan document. Appellees’ App. at 796. Applying

a de novo standard of review, the district court held that this was an erroneous

interpretation of the Plan. According to the district court, it would be

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unreasonable to interpret the “usual and customary” fee charged by an out-of-

network provider to be equivalent to the fees charged by in-network providers,

with whom the Plan negotiates discounted rates. As discussed above, the district

court’s use of a de novo standard of review was incorrect. But in analyzing this

portion of the Geddeses’ claim, the district court repeatedly invoked the language

of arbitrary and capricious review , and relied in its opinion on an Eleventh Circuit

holding reached under the arbitrary and capricious standard. W e therefore

interpret the district court as holding that United’s interpretation of “usual and

customary” is unreasonable under either standard of review, and affirm on that

ground.

St. M ary’s was a so-called “out-of-network” provider. The Plan authorizes

payment to out-of-network providers only up to an allowed amount, which the

Plan defines as “the usual and customary amount determined by the Plan.”

Appellees’ App. at 263. W hat counts as “usual and customary,” however, is not

specified in the Plan document. The disputed provision states in full:

Allow able expenses. For services provided by a participating provider.

The contracted amount of payment to which the provider has agreed. For

services provided by a non-participating provider, the usual and customary

amount as determined by the Plan.

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Id. Everest A dministrators, as U nited’s agent, defined “usual and customary” to

mean “what the plan pays on average for in-network services.” Appellants’ App.

at 166; see also Appellees’ App. at 297-98. The Geddeses, by contrast, argue the

provision reasonably means the market rate prevailing in a given geographic

region.

Under the arbitrary and capricious standard, our inquiry is limited to

determining whether the plan administrator’s interpretation of the ambiguous

language was “reasonable and made in good faith.” Fought v. Unum Life Ins. Co.

of Am ., 379 F.3d 997, 1003 (quoting Hickman v. GEM Ins. Co., 299 F.3d 1208,

1213 (10th Cir. 2002)). W e will not substitute our own judgment for that of the

plan administrator unless the administrator’s actions are without any reasonable

basis. Woolsey v. M arion Lab., 934 F.2d 1452, 1460 (10th Cir. 1991);

Restatement (Second) Trusts § 187 cmt. e. W e ask four questions derived from

the principles of trust law: (1) Is the interpretation the result of a reasoned and

principled process? (2) Is it consistent with any prior interpretations by the plan

administrator? (3) Is it reasonable in light of any external standards? And (4) is

it consistent with the purposes of the plan? Fought, 379 F.3d at 1003;

Restatement (Second) Trusts § 187 cmt. d (1959). W e answer these queries based

on the administrative record. Hall, 300 F.3d at 1201.

In the case at bar, the parties do not address whether United’s interpretation

was the result of a principled process or consistent with prior interpretations, and

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neither shall we. The G eddeses do maintain, however, that United’s

interpretation of “usual and customary” is unreasonable and unfair, implicating

the third and fourth inquiries above. Under factor three, we consider “the

existence or non-existence, the definiteness or indefiniteness, of an external

standard by which the reasonableness of the trustee’s conduct can be judged.”

Restatement (Second) Trusts § 187 cmt. d. If there is such a standard, trust law

generally holds the trustee guilty of an abuse of discretion if he contravenes it. In

re Curtis’ Trust Estate, 33 N.W .2d 193, 198 (W is. 1948) (holding that while the

trust instrument did not affirmatively require trustees to pay the beneficiary’s

taxes, such payment was reasonable and necessary to effect the purposes of the

trust). In the present case, industry custom provides a reasonable external

standard by which to evaluate United’s interpretation of the ambiguous phrase,

“usual and customary.” W hen calculating payments to non-network providers,

healthcare administrators typically rely on rate schedules assembled from a

survey of average treatment charges in a given geographic region. Hickman, 299

F.3d at 1210; Schwartz v. Oxford Health Plans, Inc., 175 F. Supp 2d 581, 589

(S.D.N.Y. 2001). Yet neither United nor Everest made any such surveys, and

United did not include rate tables or benefit schedules in the Plan. Instead,

United and Everest simply declared the “usual and customary” rate for out-of-

network providers to be the same as the average for in-network providers. The

district court found, and we agree, that interpreting a “customary” charge in the

-21-
medical market as synonymous w ith the discounted rate negotiated by a health

plan with its preferred providers is a significant deviation from industry custom.

W hat’s more, that deviation frustrates the purposes of the Plan. According

to the Plan document, United Staffing established its medical alliance “to make

health care benefits available to . . . qualifying employees and their eligible

dependents.” Appellees’ App. at 250. But United’s interpretation of “usual and

customary” effectively denies plan members medical coverage if they, like the

Geddeses, are forced to use an out-of-network provider. Nothing in the Plan

document alerts beneficiaries to this significant limitation on their medical

coverage. In fact, by juxtaposing the “contracted amount” for in-network

providers w ith the “usual and customary” charge levied by out-of-network

physicians— and by promising to cover both— the text of the Plan directly implies

the two rates are distinct, and that out-of-network expenses will be covered at the

prevailing market rate. See Appellees’ A pp. at 263.

In analyzing a similar provision in another ERISA health plan, the Eleventh

Circuit noted that the “usual and customary fee is the reasonable fee,” the fee a

prudent person would expect to pay based on the prevailing market rate. HCA

Health Serv. of Ga., Inc. v. Employers Health Ins. Co., 240 F.3d 982, 997 (11th

Cir. 2001). A prudent person “would not even consider the discounted fee

because it only arises out of a specified contractual relationship.” Id. That is, the

in-network provider fee is by definition not the usual fee charged by physicians in

-22-
any given market. The whole purpose of assembling a network of preferred

health providers is to allow the insurer to cover its beneficiaries’ expenses on a

negotiated schedule below the prevailing market rate. W e agree with the analysis

of the Eleventh Circuit in HCA Health: a reasonable, prudent person would never

suspect that the “usual and customary” fee for medical services was synonymous

with the lower, contractual fee charged by an insurer’s in-netw ork physicians.

Such an interpretation renders “usual and customary” virtually meaningless.

United’s interpretation has the effect of misleading Plan members and

denying them necessary medical coverage. Given its departure from industry

custom and its deleterious effect on Plan beneficiaries, we find United’s

interpretation of “usual and customary” arbitrary and capricious. W e agree with

the district court that “usual and customary” in this instance means the prevailing

market rate. W e affirm the district court’s order directing United to pay the

Geddeses’ St. M ary’s Hospital invoices as billed.

D. Everest’s Liability under the Statute

W e come finally to Defendant Everest’s belatedly-raised argument that the

district court lacked authority under 29 U.S.C. § 1132(d)(2) to order a money

judgment against it. Because the issue was not raised below, we may consider it

here only if the argument is purely a matter of law whose proper resolution is

certain. United Steelworkers of Am. v. Or. Steel M ills, Inc., 322 F.3d 1222, 1228

(10th Cir. 2003) (quoting Ross v. United States M arshal for E. Dist. of Ok., 168

-23-
F.3d 1190, 1195 n.5 (10th Cir. 1999)). W e believe it is. The ERISA statute is

clear: ERISA beneficiaries may bring claims against the plan as an entity and plan

administrators. Everest is neither. W e reverse the district court.

W e predicate our analysis on the district court’s conclusion that Everest

Administrators is not a fiduciary under the terms of the ERISA statute. See

Subsection II.A n.1, supra. No party to this action argues to the contrary. Under

these circumstances, we decline here to revisit that factual conclusion.

The language of 29 U.S.C. § 1132(d)(2) allows beneficiaries to bring

claims against the plan entity, and possibly against plan administrators and named

fiduciaries as well. The statute provides:

Any money judgment under this subchapter against an employee benefit

plan shall be enforceable only against the plan as an entity and shall not be

enforceable against any other person unless liability against such person is

established in his individual capacity under this subchapter.

Id.

The circuits are divided on whether beneficiaries may bring claims against

plan administrators and named fiduciaries in addition to the plan entity. But no

circuit holds that a non-fiduciary such as Everest is liable under the terms of 29

U.S.C. § 1132(d)(2). Compare Riordan v. Commonwealth Edison Co., 128 F.3d

549, 551 (7th Cir. 1997) (“It is true that ERISA permits suits to recover benefits

-24-
only against the plan as an entity. . . .”) and Lee v. Burkhart, 991 F.2d 1004, 1009

(2d Cir. 1993) (quoting Gelardi v. Pertec Com puter Corp., 761 F.2d 1323, 1324

(9th Cir. 1985) (“ERISA permits suits to recover benefits only against the plan as

an entity.”))), with Curcio v. John Hancock M ut. Life. Ins. Co., 33 F.3d 226, 233

(3d Cir. 1994) (stating that ERISA permits suits to recover benefits against the

plan as an entity and against the fiduciary of the plan); Daniel v. Eaton Corp.,

839 F.2d 263, 266 (6th Cir. 1988) (holding that the proper party in an ERISA

action concerning benefits is the party “shown to control administration of the

plan”).

This makes sense in light of traditional trust principles, as applied to the

architecture of ERISA plan administration. The statute requires that plan

administration be vested in a fiduciary, and permits the fiduciary plan

administrator to employ an agent to carry out plan responsibilities. The fiduciary

owes a duty of care to the beneficiaries, and is legally responsible both for its

own decisions and also for decisions made by its agent. Cook v. Holland, 575

S.W .2d 468, 472 (Ky. Ct. App. 1978); In re Estate of Lohm Estate, 269 A.2d 451,

455 (Pa. 1970); In re Hartzell’s Will, 192 N.E.2d 697, 706 (Ill. App. Ct. 1963);

Kenny v. Citizens Nat. Trust & Savings Bank of Los Angeles, 269 P.2d 641, 652

(Cal. Ct. App. 1954); Restatement (Second) of Trusts § 225. The agent, however,

assuming it is not a fiduciary, owes duties to the administrator and not to the

beneficiaries.

-25-
 As an independent, non-fiduciary, third party administrator, Everest might

still be liable under the statute if the G eddeses had made claims against Everest

individually, distinct from its role as U nited’s agent. But they did not. Nor did

the district court find any basis for personal liability against Everest. For these

reasons, the money judgment against Everest is reversed.

III. Conclusion

W e REVERSE the district court’s judgment as to the Primary Children’s

claims and remand for reconsideration on the administrative record, on an

“arbitrary and capricious” standard of review. W e AFFIRM the district court’s

refusal to consider United’s belated pre-certification argument. W e AFFIRM the

district court’s judgment as to the St. M ary’s claims against U nited. W e

REVERSE the district court’s money judgment against Everest.

-26-
No. 05-4142, M ichael Geddes, et al. v. United Staffing Alliance Employee
M edical Plan, et al.

H O L LO W A Y, Circuit Judge, concurring in part and dissenting in part:

I respectfully dissent from the holding that the benefits determinations

should be reviewed under the arbitrary and capricious standard. I therefore

dissent from Parts II-A and II-B of the majority opinion, and I concur only in the

result as to Part II-C. I concur in Part II-D, agreeing that the court should notice

and reverse the error of entering judgment against defendant Everest.

I

First, I disagree with the majority’s framing of the issue as “w hether a

fiduciary’s decision to delegate part of its Firestone authority to an independent

claims administrator triggers de novo review.” M aj. op. at 2. The question

instead is simply w hether any discretion was exercised to which the courts owe

deference. I believe that on this record the answer to that question is clearly no.

In this case, the fiduciary party with discretion (U nited) did not act, and the party

which acted (claims administrator Everest) had no discretion. The majority’s

holding, which is in effect that any act authorized by a party vested with

discretion must be reviewed with deference, is contrary to – rather than dictated

by – the common law of trusts, is contrary to the manifest intent of Congress for

ERISA plans to be administered by a fiduciary, and creates a circuit split by

adopting its unprecedented holding.
 The majority’s analysis is critically flawed because its underpinning is the

unsupported assumption that “discretion was exercised by some combination of

the fiduciary and its agent.” M aj. op. at 13. As I will demonstrate infra, any

suggestion that the agent exercised discretion is not supported by the evidence

concerning how the claims were handled and is directly contrary to the

contractual provision governing the relationship between the fiduciary and the

agent. Further, both the fiduciary and the agent specifically denied in their

pleadings, under constraints of Fed. R. Civ. P. 11, that the agent exercised any

discretion. And the record is clear that the fiduciary, United, did nothing at all.

Consequently, the majority’s naked assertion that some combination of the

fiduciary and its agent exercised discretion is simply that – a naked assertion

completely lacking in support.

II

Before outlining the facts and circumstances that refute the majority’s key

assumption, I think it useful to briefly state the relevant legal principles. W e said

in Gilbertson v. Allied Signal, Inc., 328 F.3d 625, 631 (10th Cir. 2003), that to be

entitled to deferential review, the administrator must actually exercise the

discretion granted by the plan. The district court applied the plain meaning of

that statement and others from Gilbertson, including this:

“[I]f a trustee fails to act or to exercise his or her discretion, de novo
review is appropriate because the trustee has forfeited the privilege
to apply his or her discretion; it is the trustee’s analysis, not his or

-2-
 her right to use discretion or a mere arbitrary denial, to which a
court should defer.”

Gilbertson, 328 F.3d at 633 (quoting Gritzer v. CBS, Inc., 275 F.3d 291, 296 (3d

Cir. 2002)) (emphasis added). I agree with the district court that this language

should be applied to the circumstances here where the administrator only acted

through the agent, which had neither discretion nor fiduciary duties. 1 No party

exercised the discretion granted by the plan; therefore, the plan administrator is

not entitled to deferential review. This seems in keeping with the common law of

trusts: “W here discretion is conferred upon the trustee . . . its exercise is not

subject to control by the court, except to prevent an abuse by the trustee of his

discretion.” Restatement (Second) of Trusts § 187 (1959) (emphasis added).

Failure to use judgment is by definition an abuse of discretion. See id. at

comm ent e.

The other circuits that have considered this issue have reached this same

conclusion. See Rodriguez-Abreu v. Chase M anhattan Bank, 986 F.2d 580, 584

(1st Cir. 1993) (“To be an effective delegation of discretionary authority so that

1
The critical legal premise of the majority opinion, it appears, is the
conclusion that 29 U.S.C. § 1105(c)(1) permits the delegation of non-fiduciaries
to carry out fiduciary responsibilities. M aj. op. at 9-10. As shown infra, no
factual basis exists for application of this conclusion of law in this case w here
only ministerial duties were delegated. M oreover, the conclusion is wrong as a
matter of law . Under ERISA, if a party exercises discretion, it is a fiduciary. 29
U.S.C. § 1002(21)(A). See also Baker v. Big Star Div. of the Grand Union Co.,
893 F.2d 288, 291 (11th Cir. 1990) (“[I]t is clear that an administrator w ith
discretionary authority is a fiduciary.”) (emphasis in original).

-3-
the deferential standard of review will apply, therefore, the fiduciary must

properly designate a delegate for the fiduciary’s discretionary authority.”);

M adden v. ITT Long Term Disability Plan, 914 F.2d 1279, 1283-85 (9th Cir.

1990) (“[W]e hold that where . . . a named fiduciary properly designates another

fiduciary, delegating its discretionary authority, the ‘arbitrary and capricious’

standard of review . . . applies . . . .”); and Baker v. Big Star Div. of the Grand

Union Co., 893 F.2d 288, 291 (11th Cir. 1990). See also Nichols v. Prudential

Ins. Co., 406 F.3d 98, 109 (2d Cir. 2005) (“[W]e conclude that we may give

deferential review only to actual exercises of discretion.”).

The majority opinion relies heavily on its reading of the statutory provision

authorizing delegation of duties. That provision states, in pertinent part:

The instrument under which a plan is maintained may expressly
provide for procedures (A) for allocating fiduciary responsibilities
(other than trustee responsibilities) among named fiduciaries, and (B)
for named fiduciaries to designate persons other than named
fiduciaries to carry out fiduciary responsibilities (other than trustee
responsibilities) under the plan.

29 U.S.C. § 1105(c)(1). 2

2
It appears to me that a line was inadvertently dropped in the district
court’s quotation from this statute and that the district judge meant to quote the
relevant parts of the provision just as the majority opinion does. This seems
likely to me for two reasons. First, the district court opinion introduces its
abbreviated quote from the statute by saying that ERISA provides that a named
fiduciary may delegate its fiduciary responsibilities. But the provision as quoted
in the district court opinion does not say that at all. In fact, the edited version
that appears in that opinion merely states what is, under ERISA , a truism: that
the plan may provide for named fiduciaries to carry out fiduciary responsibilities.
(continued...)

-4-
 In this case, there was no designation of any other person to carry out

fiduciary responsibilities. I do not doubt that the named fiduciary may, as United

did here, also designate another, Everest in this case, to carry out ministerial

functions. See 29 C.F.R. § 2509.75-8, D-2. Or, as in M adden, the named

fiduciary may designate another fiduciary to perform discretionary duties, and

discretionary decisions by the designated fiduciary will be reviewed deferentially.

But it is precisely because ministerial, and not discretionary or fiduciary, duties

were delegated – combined with the key fact that United did not exercise its

retained discretionary authority – that no deference is due the decisions made. 3

I realize that United’s delegation of duties to Everest does not relieve it of

liability because it is bound by the acts of its agent, as the majority opinion notes.

2
(...continued)
Second, the district judge goes on to discuss with apparent approval the holding
of M adden that where “a named fiduciary properly designates another fiduciary,
delegating its discretionary authority, the ‘arbitrary and capricious standard’ . . .
applies to the designated ERISA -fiduciary as well as to the named fiduciary.”
This discussion also is inconsistent with the truncated version of the statutory
provision as quoted in the district court’s opinion.
3
The majority opinion says that the fact that Everest handled every claim
“led the district court to conclude that United Staffing effectively did nothing,
totally failing for purposes of the ERISA statute and Gilbertson to exercise its
discretion and thereby forfeiting its claim to deferential review.” M aj. op. at 9.
But the district court did not merely draw an inference that U nited did nothing.
The evidence was clear and undisputed, and based entirely on the deposition
testimony of United’s representative, that United did nothing. The question is
whether a fiduciary which has reserved to itself all fiduciary obligations and all
discretion and then does nothing should be afforded the same deferential review
that we would give to the decisions of a fiduciary which actually exercised its
reserved discretion to make the final determinations on contested claims.

-5-
But surely this statute’s purposes go beyond ensuring that someone can he held

liable through court action.

Under the ERISA scheme, a plan administrator exercises the function of

handling claims w ith fiduciary responsibilities to the plan’s beneficiaries. This

seems to be close to the very heart of the legislative plan: “It is hereby declared

to be the policy of this chapter to protect . . . the interests of participants in

employee benefit plans and their beneficiaries, by . . . establishing standards of

conduct, responsibility, and obligation for fiduciaries of employee benefit plans . .

. .” 29 U.S.C. § 1001(b).

M ore importantly, the issue here is not whether United may be liable for

Everest’s actions undertaken as United’s agent. Of course United may be so

liable. The issue instead is whether, in deciding whether liability should be

imposed in this case, the court should review the decisions deferentially. And

there is simply no basis shown for such deference where the decisions were

ministerial, rather than discretionary, in character. In this case the fiduciary

clearly failed to exercise its discretion and instead simply defaulted to the non-

fiduciary agent, which expressly was not endowed with discretion, to carry out

duties that ERISA assigns to a fiduciary. Because no discretion was exercised, no

deference is due to the decisions made. In the alternative, however, I would hold

that the decisions as to the Primary Children’s Hospital claims which w ere

handled in this perfunctory fashion were arbitrary and capricious. The following

-6-
discussion illustrates both that the acts were not discretionary and that the

decisions were arbitrary and capricious.

III

I disagree that the majority’s result is supported by our decision in

Gilbertson, but it is useful to note the factual differences in the cases. W e noted

in Gilbertson that the plan administrator had delegated its discretion to the third-

party claims administrator and that the plan documents expressly authorized such

delegation. But this case is quite different. In this case the plan document

provided:

The Company is the named fiduciary and is the plan administrator of
the Plan. The Company will engage an independent claims
administrator to administer the Plan, however, the Company makes
all final decisions about benefits paid from the Plan.

Aple. Supp. App. 250 (italics in original). This is not language delegating

discretionary authority or fiduciary responsibilities. See Nichols v. Prudential

Ins. Co., 406 F.3d 98, 108-09 (2d Cir. 2005) (discussing language that is effective

to vest discretion in an administrator).

M oreover, the defendants in this case have resolutely and consistently taken

the position that Everest exercised no discretion and was not a fiduciary. Both

specifically denied in pleadings that Everest was vested with discretion. In the

Complaint, plaintiffs had alleged on information and belief that both United and

-7-
Everest had discretionary authority. Aple. Supp. App. 3, ¶ 12. Both defendants

specifically denied the allegation. Id. at 12, 19.

The contract under which Everest acted was quite clear on the point:

The Contract Administrator [Everest] shall not be deemed a Plan
“fiduciary” as defined in ERISA . [Everest’s] services shall not
include any power to make decisions regarding Plan policy,
interpretations, practices or procedures, but shall be confined to
ministerial functions such as those described by the U.S. Department
of Labor in its Regulations Section 2509.75-8, D-2. . . . . [Everest]
shall have no final discretionary control over Plan management,
including disposition of Plan assets and Plan administration.
[Everest’s] services hereunder shall be subject to review,
modification, or reversal by the Plan Sponsor and/or Plan
Administrator.

Id. at 271 (emphasis added).

As to the claims for Andrew’s treatment at Primary Children’s Hospital, the

subject of Part II-B of the majority opinion, the deposition testimony of the

witness designated to speak for Everest further reveals the ministerial or clerical

nature of Everest’s services. The witness testified that the process of reviewing

the claims for Andrew’s treatment at that hospital consisted almost entirely of

reading the numerical code used by the hospital to categorize the service and

comparing that with the plan’s coverage language:

Q. Now, when a claim would come in under this plan, give me an
idea of how it was decided whether the claim would be paid, how
much would be paid, or whether it would be denied.

A. The basis for doing that is, of course, the provisions of the
master plan document and the way that the care is coded or
represented by the care provider.

-8-
 There are universal codes, diagnosis codes, service codes that are
used in the medical care field. And those codes are required to be on
the bill. If they’re not, then we are not able to process the bill. . . . .
And those codes are a way that the care provider themselves
represents what the care provided was, what classification, what
category of care it was. And from those codes we can determine
which category on the schedule of benefits is the one that applies.

Again, it’s a matter of correctly inputting the care codes in the
claims administrator system. And that gives the claims administrator
the information they need to categorize the care.

Once the care is categorized, then the schedule of benefits dictates
how the benefit payment is made. . . . .

....

But I think it’s a pretty good summary of what happens to say that
it’s a matter of taking the codes that the care provider has assigned to
the care they provided. That helps us categorize the care. And then
from then – from that point on, the master plan document dictates
what benefit is payable by the plan.

****

Q. So then who makes the determination after that of the category
that that particular type of service falls into?

A. Almost without exception, the provider of care has categorized
the service that they have provided by coding it in a certain way. So
– when you use the term judgment, to me, that means that there’s
some sort of judgment decision to make. And for the most part,
that’s not the case. It’s a matter of simply – of correctly reading
what the care provider codes are and putting it in the correct –
putting it in the category that the care provider has assigned it to.

Id. at 401-04 (testimony of Ronald C . Hulse).

This is, so far as I can determine, the best description available of how the

claims for care at Primary Children’s Hospital were handled. The hospital chose

-9-
to use the numerical code for rehabilitative services rather than the code for

services connected with hospitalization for most of the services provided.

Rehabilitative services were limited under the plan to $2,500.00. Everest read the

codes used by the hospital and mechanically applied the limitation stated in the

plan. This is the “exercise of discretion” to which, the majority holds, deference

is required.

Because I disagree with the fundamental premise that discretion was

exercised by Everest as agent for United, I see no basis for employment of the

deferential standard of review. I therefore respectfully dissent from the holdings

in Parts II-A and II-B of the majority opinion and would affirm the district court’s

judgment on the claims involving care provided at Primary Children’s H ospital. 4

I concur in the result of Part II-C, which affirms the district court’s judgment on

the claims involving care provided at St. M ary’s Hospital, but for the reasons set

out herein I would reach that result by affirming the district court’s analysis under

de novo review rather than by re-examining the claims under the arbitrary and

capricious standard.

4
After holding that the de novo standard of review applied because the
delegation of responsibilities was to a non-fiduciary and no fiduciary ever
review ed the Geddes’ claims, the district judge noted that his holding made it
unnecessary to determine whether the de novo standard should be applied for
another reason – the Geddes’ allegation that the administrator failed to follow its
claims and appeals procedures. I feel it appropriate to note that the district court
is free to address that issue on remand.

-10-
 IV

For the reasons stated in Part II-D of the majority opinion, I agree that the

monetary judgment against Everest should be reversed.

-11-