{ "id": 520916, "name": "MARIE A. BOYD, Plaintiff-Appellant, v. PEORIA JOURNAL STAR, INC., Defendant-Appellee", "name_abbreviation": "Boyd v. Peoria Journal Star, Inc.", "decision_date": "1997-04-23", "docket_number": "No. 3\u201496\u20140792", "first_page": "796", "last_page": "800", "citations": [ { "type": "official", "cite": "287 Ill. App. 3d 796" } ], "court": { "name_abbreviation": "Ill. App. Ct.", "id": 8837, "name": "Illinois Appellate Court" }, "jurisdiction": { "id": 29, "name_long": "Illinois", "name": "Ill." }, "cites_to": [ { "cite": "992 F.2d 113", "category": "reporters:federal", "reporter": "F.2d", "case_ids": [ 11951780 ], "year": 1993, "pin_cites": [ { "page": "114" } ], "opinion_index": 0, "case_paths": [ "/f2d/992/0113-01" ] }, { "cite": "266 Ill. App. 3d 489", "category": "reporters:state", "reporter": "Ill. App. 3d", "case_ids": [ 887265 ], "year": 1994, "pin_cites": [ { "page": "493" } ], "opinion_index": 0, "case_paths": [ "/ill-app-3d/266/0489-01" ] }, { "cite": "984 F.2d 762", "category": "reporters:federal", "reporter": "F.2d", "case_ids": [ 10516042 ], "year": 1993, "pin_cites": [ { "page": "765" } ], "opinion_index": 0, "case_paths": [ "/f2d/984/0762-01" ] }, { "cite": "103 Ill. App. 3d 335", "category": "reporters:state", "reporter": "Ill. App. 3d", "case_ids": [ 5483576 ], "year": 1982, "pin_cites": [ { "page": "339" } ], "opinion_index": 0, "case_paths": [ "/ill-app-3d/103/0335-01" ] }, { "cite": "29 U.S.C. \u00a7 1132", "category": "laws:leg_statute", "reporter": "U.S.C.", "year": 1991, "pin_cites": [ { "page": "(1)(1)(B)" } ], "opinion_index": 0 } ], "analysis": { "cardinality": 495, "char_count": 9121, "ocr_confidence": 0.766, "pagerank": { "raw": 4.03580807328026e-08, "percentile": 0.01852907254438386 }, "sha256": "02ac61353e8287db9aef78e6302240085392d25faadbfcf0c012f82264c618fa", "simhash": "1:c8664cc28407a081", "word_count": 1382 }, "last_updated": "2023-07-14T19:23:12.186621+00:00", "provenance": { "date_added": "2019-08-29", "source": "Harvard", "batch": "2018" }, "casebody": { "judges": [], "parties": [ "MARIE A. BOYD, Plaintiff-Appellant, v. PEORIA JOURNAL STAR, INC., Defendant-Appellee." ], "opinions": [ { "text": "JUSTICE MICHELA\ndelivered the opinion of the court:\nMarie A. Boyd filed an action in the circuit court of Tazewell County against her employer, Peoria Journal Star, Inc., seeking recovery for medical expenses under a health insurance plan known as \"The Peoria Journal Group Health Benefit Plan\u201d (the Plan). The court granted defendant\u2019s motion for summary judgment and denied plaintiffs countermotion for summary judgment.\nOn appeal, plaintiff seeks reversal of the court\u2019s decision, contending that it erred in finding the Plan contained no provisions for, and specifically excluded coverage for, the surgical removal of her defective prosthesis. Plaintiff contends further that defendant\u2019s interpretation of the Plan was irrational, arbitrary, and capricious, in violation of the Employee Retirement Income Security Act (ERISA) (29 U.S.C. \u00a7 1132(1)(1)(B) (Supp. 1991)). In the alternative, plaintiff requests that this court find that defendant\u2019s select review of medical evidence created a question of fact as to whether defendant\u2019s decision was arbitrary and capricious, and remand the cause for further proceedings. For the following reasons, we reverse.\nFacts\nIn March 1983, plaintiff developed temporomandibular joint syndrome (TMJS), which necessitated the replacement of her temporomandibular joint (TMJ) with a TMJ implant (prosthesis).\nIn October 1993, plaintiff\u2019s oral surgeon, Dr. Russell A. Williams, notified defendant that due to resorption occurring around plaintiffs prosthesis, and the potential for brain exposure, her prosthesis must be removed. Dr. Williams informed defendant of his surgical plan, and surgery was scheduled for November 1993. Prior to surgery, defendant notified Dr. Williams and plaintiff of its denial of plaintiffs benefit claim.\nIn January 1994, plaintiff filed her complaint against defendant, which was later amended, and alleged, inter alia, that in violation of ERISA, defendant\u2019s decision to deny her benefits was based on an irrational, arbitrary, and capricious interpretation of the Plan.\nIn April 1994, plaintiff underwent surgical removal of her prosthesis at a reported cost of $30,000. In December 1994, defendant filed a motion for summary judgment, and in May 1995, plaintiff filed a countermotion for summary judgment. In August 1995, the court granted defendant\u2019s motion, denied plaintiff\u2019s countermotion, and plaintiff appeals.\nAnalysis\nPlaintiff contends that the court erred in granting defendant\u2019s motion for summary judgment and in denying her countermotion for summary judgment. A motion for summary judgment should be granted if the pleadings, depositions, and admissions on file, together with any affidavits, show that there is no genuine issue of material fact and that the moving party is entitled to a judgment as a matter of law. Boylan v. Martindale, 103 Ill. App. 3d 335, 339 (1982).\nIn this matter, plaintiff asserts that the court erred in finding that the Plan contained no provisions for, and specifically excluded coverage for, the surgical removal of her defective prosthesis. Plaintiff maintains that, in violation of ERISA, defendant\u2019s interpretation of the Plan was unreasonable, arbitrary, and capricious.\nWhen a trustee is given the discretion to construe a plan\u2019s terms and allocate benefits, judicial review is limited to whether that decision was arbitrary and capricious. Russo v. Health, Welfare & Pension Fund, Local 705, 984 F.2d 762, 765 (7th Cir. 1993). The arbitrary and capricious standard only requires that a trustee\u2019s decision make sense, and something more than an alternative interpretation is needed to override such decision. Russo, 784 F.2d at 766. Great deference is given to the trustees\u2019 decision, and it will not be disturbed when it is based on a reasonable interpretation of a plan\u2019s language and evidence in the case. Russo, 784 F.2d at 765.\nWe note that while it is axiomic that contracts are considered as a whole, and are not read in isolated pieces, full effect should be given to more principal and specific clauses, and general clauses should be subject to modification or qualification necessitated by specific clauses. Herington v. J.S. Alberici Construction Co., 266 Ill. App. 3d 489, 493 (1994).\nIn support of her position that the Plan does provide her with coverage, plaintiff relies in part upon subsections (c) and (e) of the Plan\u2019s deductible medical benefits section, which grant coverage for such things as in-patient hospital services, physicians\u2019 surgical services, anesthetics, and radiologist or laboratory services. However, plaintiff acknowledges that in addition to its own stated limitations, the Plan\u2019s deductible medical benefits section is subject to the exclusions found in the Plan\u2019s general limitations section. The general limitations section states in pertinent part:\n\"In addition to any limitations or exclusions stated in the respective benefit descriptions, no benefits are payable under this Plan for Expenses Incurred:\n* * *\n(c) for or in connection with:\n* * *\n(20) treatment of temporomandibular joint syndrome with intraoral prosthetic devices, or any other procedure to alter vertical dimension.\u201d (Emphasis added.)\nIn determining whether an \"in connection with\u201d exclusion applies, the court in Kraut v. Wisconsin Laborers Health Fund, 992 F.2d 113, 114 (7th Cir. 1993), stated that the purpose rather than the location of the surgery is the critical inquiry.\nIn the present matter, on November 17, 1993, Dr. Williams wrote to defendant and requested that it reconsider its decision denying plaintiff benefits. In doing so, Dr. Williams thoroughly explained his position as to why plaintiff\u2019s surgery did not fall within the exclusion \"for or in connection with\u201d the treatment of TMJS with intraoral devices or any procedure to alter vertical dimension. Dr. Williams noted, inter alla, that plaintiff neither has, nor shows symptoms of, TMJS and that her prosthesis must be removed due to resorption.\nFurther, a May 1995 affidavit from Dr. Williams reemphasizes the purpose of plaintiffs surgery. Importantly, Dr. Williams states therein:\n\"In 1992, 1993, and 1994,1 did not treat Marie Boyd for or in connection with [TMJS] or any other procedure to alter vertical dimension. Marie had no symptoms or clinical findings attributable to [TMJS]. No intraoral devices were utilized in her surgery. Any alteration of vertical dimension would be considered a problem or complication of the surgery to remove the protheses ***.\"\nDefendant failed to present medical evidence to refute Dr. Williams\u2019 opinion as to the purpose of plaintiffs surgery. Although defendant\u2019s employee relation\u2019s manager, John Swingle (Swingle), testified at his deposition that he left it up to the Plan\u2019s third-party administrator, Employee Benefits Corporation (EBC), to \"look at [plaintiffs] symptoms or procedures or whatever was involved,\u201d he stated that EBC did not provide, nor did he request, any written document outlining its reasons for recommending denial of benefits.\nIn further response to his failure to consider plaintiffs resorption symptoms, Swingle stated, \"[t]he point was that removal of the implants, in my opinion and the opinion of the EBC, was most certainly related to the original TMJ surgery.\u201d Swingle\u2019s comment suggests that the decision to deny plaintiff benefits was exclusively based on the fact that in 1983 she suffered from TMJS and underwent a surgical replacement of her TMJ with a prosthesis.\nWe find that defendant\u2019s reading of the Plan was based on neither a reasonable interpretation of the Plan\u2019s language nor on the evidence presented. Dr. Williams\u2019 correspondence, coupled with his affidavit, establishes that the 1994 surgical removal of plaintiff\u2019s prosthesis, where no intraoral devices were used, was neither a procedure that treated or was in connection with her 1983 TMJS, nor was it performed to alter her vertical dimension. Therefore, subsection (c)(20) of the Plan\u2019s general limitations section does not bar plaintiffs claim for benefits. As no material question of fact exists, plaintiff is entitled to summary judgment as a matter of law.\nUnder these circumstances, the court erred in granting defendant\u2019s motion for summary judgment and in denying plaintiff\u2019s countermotion for summary judgment. In light of our disposition of this issue, it is unnecessary for us to consider plaintiff\u2019s alternative contention regarding defendant\u2019s alleged select review of medical evidence.\nBased on the foregoing, we reverse the Tazewell County circuit court\u2019s grant of defendant\u2019s motion for summary judgment and denial of plaintiff\u2019s countermotion for summary judgment.\nReversed.\nLYTTON, P.J., and SLATER, J., concur.", "type": "majority", "author": "JUSTICE MICHELA" } ], "attorneys": [ "Steven A. Wakeman, James P. Lawson (argued), and Craig Reiser, all of Kingery, Durree, Wakeman & Ryan, Associates, of Peoria, for appellant.", "Matthew B. Smith (argued) and Mary W. McDade, both of Quinn, Johnston, Henderson & Pretorius, of Peoria, for appellee." ], "corrections": "", "head_matter": "MARIE A. BOYD, Plaintiff-Appellant, v. PEORIA JOURNAL STAR, INC., Defendant-Appellee.\nThird District\nNo. 3\u201496\u20140792\nOpinion filed April 23, 1997.\nRehearing denied May 27, 1997.\nSteven A. Wakeman, James P. Lawson (argued), and Craig Reiser, all of Kingery, Durree, Wakeman & Ryan, Associates, of Peoria, for appellant.\nMatthew B. Smith (argued) and Mary W. McDade, both of Quinn, Johnston, Henderson & Pretorius, of Peoria, for appellee." }, "file_name": "0796-01", "first_page_order": 814, "last_page_order": 818 }