Filed: Jun. 04, 2002
Latest Update: Feb. 12, 2020
Summary: UNPUBLISHED UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT DONNA S. MEREDITH, Plaintiff-Appellee, v. MAMSI INSURANCE RESOURCES, No. 01-2188 INCORPORATED, d/b/a MAMSI Life and Health Insurance Company, Defendant-Appellant. Appeal from the United States District Court for the Southern District of West Virginia, at Bluefield. David A. Faber, District Judge. (CA-99-1015-1) Argued: April 2, 2002 Decided: June 4, 2002 Before WILKINSON, Chief Judge, KING, Circuit Judge, and HAMILTON, Senio
Summary: UNPUBLISHED UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT DONNA S. MEREDITH, Plaintiff-Appellee, v. MAMSI INSURANCE RESOURCES, No. 01-2188 INCORPORATED, d/b/a MAMSI Life and Health Insurance Company, Defendant-Appellant. Appeal from the United States District Court for the Southern District of West Virginia, at Bluefield. David A. Faber, District Judge. (CA-99-1015-1) Argued: April 2, 2002 Decided: June 4, 2002 Before WILKINSON, Chief Judge, KING, Circuit Judge, and HAMILTON, Senior..
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UNPUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
DONNA S. MEREDITH,
Plaintiff-Appellee,
v.
MAMSI INSURANCE RESOURCES, No. 01-2188
INCORPORATED, d/b/a MAMSI Life
and Health Insurance Company,
Defendant-Appellant.
Appeal from the United States District Court
for the Southern District of West Virginia, at Bluefield.
David A. Faber, District Judge.
(CA-99-1015-1)
Argued: April 2, 2002
Decided: June 4, 2002
Before WILKINSON, Chief Judge, KING, Circuit Judge, and
HAMILTON, Senior Circuit Judge.
Affirmed by unpublished per curiam opinion.
COUNSEL
ARGUED: James Carson Stebbins, HUDDLESTON, BOLEN,
BEATTY, PORTER & COPEN, L.L.P., Charleston, West Virginia,
for Appellant. William Bernard Flanigan, SANDERS, AUSTIN,
PRUDICH & FLANIGAN, Princeton, West Virginia, for Appellee.
2 MEREDITH v. MAMSI INSURANCE RESOURCES
Unpublished opinions are not binding precedent in this circuit. See
Local Rule 36(c).
OPINION
PER CURIAM:
This is an action under the Employee Retirement Income Security
Act (ERISA), 29 U.S.C. §§ 1001-1461, in which Donna Meredith
(Meredith) challenged the denial of health care benefits to cover costs
associated with the surgical implantation of metal posts into her man-
dible, i.e., endosseous implants (Endosseous Implants), which mandi-
ble had been newly reconstructed using a bone graft from her hip. Id.
at § 1132(a)(1)(B). The record is undisputed that the reconstruction of
Meredith’s mandible was medically necessary to treat a degenerative
condition in the mandibular bones in her face. The record is also
undisputed that the Endosseous Implants were medically necessary to
prevent the pathological fracture of Meredith’s newly reconstructed
mandible, to stimulate the apposition of bone, and to allow her to
open and close her mouth in order to intake food normally.
The district court granted summary judgment in favor of Meredith.
MAMSI Life and Health Insurance Company (MAMSI), the defen-
dant in this action,1 filed the present appeal. For reasons that follow,
we affirm.
I.
Meredith has a degenerative condition that causes severe bone atro-
phy of her mandibular bones, which in turn causes her facial struc-
1
Meredith formally brought the present action against "MAMSI Insur-
ance Resources, Inc. d/b/a MAMSI Life and Health Insurance Com-
pany." MAMSI points out and the record supports that MAMSI is the
legal entity that issued the policy in question, and therefore, should be
treated as the proper defendant/appellant in this action. According to
MAMSI’s opening brief, MAMSI Insurance Resources, Inc. does not
even sell health or other insurance policies.
MEREDITH v. MAMSI INSURANCE RESOURCES 3
2
tures to collapse. The collapsing of her facial structures seriously
interfered with her ability to intake food normally. Meredith is a par-
ticipant under a group health plan (the Plan) issued by MAMSI. All
parties agree that the Plan is subject to ERISA.
Of relevance in the present appeal, on October 29, 1996, Mere-
dith’s oral surgeon, Dr. John Gregg (Dr. Gregg), sought preauthoriza-
tion under the Plan for two surgical procedures in order to treat
Meredith’s degenerative condition: (1) reconstruction of her mandible
using a bone graft from her hip (the Bone Graft); and (2) the Endosse-
ous Implants. MAMSI initially denied coverage for both procedures.3
MAMSI denied coverage for the Endosseous Implants based upon a
specific exclusion in the Plan for "Dental Implants." (J.A. 37).
In order to put the remainder of the chronology of events relevant
to this appeal in proper context, we must first set forth the relevant
language of the Plan. The Coverages Section of the Plan provides
coverage for health care services "provided by a Physician or Health
Care Practitioner received in a Provider’s office . . . or Institution,
which are Medically Necessary for treatment of an Injury or Sickness
. . . ." (J.A. 33). The Exclusions Section of the Plan, specifically
Exclusion 25, provides that the Plan does not cover "Dental care,
except as related to adjunctive dental care, (see Sub-Section B- Pro-
fessional Services of the [Coverages Section of the Plan])" (J.A. 37)
(emphasis added). Sub-Section B- Professional Services of the Cover-
ages Section of the Plan provides in relevant part:
Services provided by a Physician or other licensed and qual-
ified health care practitioner received in a Provider’s office
or Institution, which are Medically Necessary for treatment
of adjunctive dental care, which means: 1) dental care that
is Medically Necessary in the treatment of a covered medi-
cal condition, is an integral part of the treatment of such
2
Because this case is on appeal from the granting of summary judg-
ment, we view all facts and reasonable inferences therefrom in the light
most favorable to MAMSI as the nonmoving party. Matsushita Elec.
Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587-88 (1986).
3
MAMSI subsequently agreed to cover the Bone Graft. Thus, this
appeal does not present a coverage issue with respect to the Bone Graft.
4 MEREDITH v. MAMSI INSURANCE RESOURCES
medical condition, and is essential to the control of the pri-
mary medical condition . . . .
(J.A. 33) (emphasis added).4 Paragraph B.3 of the Coverages Section
of the Plan is qualified by the following language found immediately
under the title to the Coverages Section of the Plan:
Subject to all other provisions of this [Plan], the Company
will pay the applicable Percentage Payable of the Usual,
Customary and Reasonable Charges, but not to exceed Life-
time Maximum Benefit or Limits, if any, for the following
Health Services for Members, provided: the expense is
Medically Necessary; and the expense is incurred and the
service is rendered while the Member is insured for this ben-
efit or while covered under the Extension of Benefits provi-
sion.
(J.A. 32) (emphasis added). Because Paragraph B.3 of the Coverages
Section of the Plan is subject to all other provisions of the Plan,
Exclusion 26 of the Plan takes away part of the coverage provided in
that paragraph by expressly excluding coverage for "Dental
Implants." (J.A. 37). Notably, the term "Dental Implants" is not
defined in the Plan.
Returning to the chronology of events relevant to this appeal, by
letter dated February 13, 1997, Dr. Gregg sought reconsideration of
MAMSI’s denial of coverage for the Endosseous Implants. In the let-
ter, Dr. Gregg clarified that the primary purposes of the Endosseous
Implants were to prevent the pathologic fracture of Meredith’s mandi-
ble and to permit her to open and close her mouth for normal food
intake. Dr. Gregg also clarified that such implantation would not be
done for cosmetic or dental purposes.
On March 17, 1997, MAMSI agreed to cover the Bone Graft. How-
ever, MAMSI continued to deny coverage for the Endosseous
Implants. At some time thereafter, Meredith’s dental physician, Dr. E.
Lynn Veneri (Dr. Veneri), wrote the following in a letter to MAMSI
4
From this point forward, we will refer to this quoted language as Para-
graph B.3 of the Coverages Section of the Plan.
MEREDITH v. MAMSI INSURANCE RESOURCES 5
in support of Meredith’s claim for coverage regarding the Endosseous
Implants:
There was severe bony atrophy to the extent that pathologi-
cal fracture was of great concern. IT WAS RECOM-
MENDED THAT THE PATIENT BE TREATED WITH A
MANDIBULAR FIXED IMPLANT PROSTHESIS.
THERE HAS BEEN RECENT STUDIES RECOMMEND-
ING THIS TREATMENT SINCE IT HAS BEEN
OBSERVED THAT THIS TYPE OF PROSTHESIS STIM-
ULATES THE APPOSITION OF BONE LESSENING
THE POTENTIAL OF FRACTURE. It is my opinion the
treatment of this individual’s clinical situation should not be
treated with a removable prosthesis which would further
cause bone loss exposing this patient to a fracture that would
be questionable in my opinion if it could be repaired. I
would like to emphasize that my opinion is based solely on
my concern due to her age, severe bone loss and ability to
masticate her food.
(J.A. 101).
Meredith underwent both procedures and submitted a claim for
coverage of both procedures.5 MAMSI paid the claim for the Bone
Graft as agreed, but continued to deny coverage for the Endosseous
Implants.
Meredith filed the present denial of coverage action in state court.
MAMSI removed the case to the United States District Court for the
Southern District of West Virginia on the basis of federal question
jurisdiction, i.e., ERISA. Following discovery, the parties filed cross-
motions for summary judgment.
5
At the time of her surgery, Meredith did not have any natural teeth.
She had been wearing dentures. However, the bone atrophy in her face
had grown so severe that her dentures had almost no support and a sig-
nificant risk existed that when eating, Meredith’s remaining facial bones
would fracture.
6 MEREDITH v. MAMSI INSURANCE RESOURCES
In its motion for summary judgment, MAMSI insisted that the
Endosseous Implants are "Dental Implants," and thus are expressly
excluded under Exclusion 26 of the Plan. In support, MAMSI offered
the deposition testimony of its Dental Director, Dr. Lee Shapiro (Dr.
Shapiro), in which Dr. Shapiro relied upon the following definition of
"endosseous implants" from Dorland’s Illustrated Medical Dictionary:
A dental implant, usually of metal, or less commonly, of
ceramic or polymeric material, consisting of a blade, screw,
pin or vent, which is inserted into the jaw bone through the
alveolar or basal bone, either directly or through the root
canal in the apex of a tooth, with a post protruding through
mucoperiosteum into the oral cavity to serve as an abutment
for dentures or orthodontic appliances, or to serve in fracture
fixation.
Dorland’s Illustrated Medical Dictionary 827 (28th ed. 1994).
According to an affidavit given by Dr. Shapiro, "‘Endosseous
implants’ are ‘dental implants’ within the common usage of that
term." (J.A. 131). MAMSI also relied upon descriptive materials pro-
vided by Nobel Biocare/Branemark, the manufacturer of the Endosse-
ous Implants used in Meredith’s surgery, which descriptive materials
indicate that the implants are designed as replacements for the root
portions of missing natural teeth and can serve as anchors for replace-
ment teeth. In her motion for summary judgment, Meredith primarily
relied upon the two letters written by Dr. Gregg and the single letter
written by Dr. Veneri that were sent to MAMSI.
Because the Plan did not vest MAMSI with discretionary authority
to interpret the Plan’s terms in making coverage decisions, the district
court reviewed MAMSI’s denial of Meredith’s claim for coverage of
the Endosseous Implants de novo. Firestone Tire & Rubber Co. v.
Bruch, 489 U.S. 101, 115 (1989) ("[A] denial of benefits . . . is to be
reviewed under a de novo standard unless the benefit plan gives the
administrator or fiduciary discretionary authority to determine eligi-
bility for benefits or to construe the terms of the plan."). All parties
agree that this was the proper standard of review.
Reviewing MAMSI’S denial of Meredith’s claim de novo, the dis-
trict court granted summary judgment in favor of Meredith for the fol-
lowing reasons:
MEREDITH v. MAMSI INSURANCE RESOURCES 7
The court believes that plaintiff’s condition comes
squarely within the definition of "adjunctive dental care"
within the policy. Adjunctive dental care is that which is
"medically necessary in the treatment of a covered medical
condition, is an integral part of the treatment of such medi-
cal condition, and is essential to the control of the primary
medical condition." See paragraph B.3 of the coverages sec-
tion of the policy.
Here, the medical evidence establishes that plaintiff has
a degenerative condition of the jaw causing her facial struc-
tures to collapse and interfering with her ability to chew and
intake food normally. There was significant danger that her
jaw bones would break if the condition were not corrected.
The accepted treatment is a bone graft accompanied by
implants to prevent fracture and permit normal food intake.
Thus, the devices, while technically falling within the defi-
nition of implants, are designed to correct the underlying
medical condition — deterioration of the bones of the jaw.
The evidence of record establishes that the implants are an
integral part of the treatment of plaintiff’s condition, are
medically necessary and essential to control of the condi-
tion.
(J.A. 180-81). Thus, the district court granted Meredith’s motion for
summary judgment, denied MAMSI’s cross-motion for summary
judgment, and entered judgment in favor of Meredith "in the sum of
$7,715.00, interest and costs." (J.A. 182).
MAMSI timely noted the present appeal. On appeal, MAMSI con-
tends the district court erroneously concluded that Exclusion 26 did
not apply.
II.
Summary judgment is appropriate when "the pleadings, deposi-
tions, answers to interrogatories, and admissions on file, together with
the affidavits, if any, show that there is no genuine issue as to any
material fact and that the moving party is entitled to judgment as a
matter of law." Fed. R. Civ. P. 56(c). "We review a grant of summary
8 MEREDITH v. MAMSI INSURANCE RESOURCES
judgment de novo, applying the same standard as the district court."
Baber v. Hospital Corp. of Am., 977 F.2d 872, 874 (4th Cir. 1992).
In so doing, we view all facts and reasonable inferences therefrom in
the light most favorable to the nonmoving party. Matsushita Elec.
Indus.
Co., 475 U.S. at 587-88.
III.
On appeal, MAMSI does not take issue with the district court’s
conclusion that surgical implantation of the Endosseous Implants was
medically necessary to treat Meredith’s degenerative condition. None-
theless, MAMSI contends that the Endosseous Implants are "Dental
Implants," and therefore, excluded from coverage pursuant to Exclu-
sion 26 of the Plan. Cutting to the heart of the matter, the only issue
on appeal is whether, viewing the evidence in the light most favorable
to MAMSI, a reasonable trier of fact could only conclude that the
Endosseous Implants that were surgically implanted into Meredith’s
mandible were not "Dental Implants" within the meaning of Exclu-
sion 26. Tester v. Reliance Std. Life Ins. Co., 228 F.3d 372, 375 (4th
Cir. 2000) (declaring that "ERISA plans are contractual documents,
and established principles of contract and trust law govern their inter-
pretation") (internal quotation marks omitted).
Viewing the evidence in the light most favorable to MAMSI, we
hold that a reasonable trier of fact could only conclude that the
Endosseous Implants that were surgically implanted into Meredith’s
mandible were not "Dental Implants" within the meaning of Exclu-
sion 26. Meredith’s treating physicians, Dr. Gregg and Dr. Veneri,
unequivocally stated that the only purposes for the Endosseous
Implants with respect to Meredith were medical as opposed to dental
in nature. Specifically, the purposes identified were to prevent frac-
ture of Meredith’s newly reconstructed mandible, to stimulate the
apposition of bone, and to allow her to open and close her mouth so
that she could intake food normally.
No evidence in the record refutes the opinions of these physicians.
Notably, Dr. Shapiro’s statement in his affidavit that "‘Endosseous
implants’ are ‘dental implants’ within the common usage of that
term," (J.A. 131), is not inconsistent with the opinions of these physi-
cians as to why Meredith needed the Endosseous Implants. As is
MEREDITH v. MAMSI INSURANCE RESOURCES 9
obvious from simply reading their letters, their respective uses of the
term "Endosseous Implants" were not within the common usage of
the term "Dental Implants" as that term is medically defined. More-
over, because Meredith’s treating physicians did not use the term "En-
dosseous Implants" within the common usage of that term, the
medical dictionary definition relied upon by Dr. Shapiro is also inap-
posite. That definition applies only when Endosseous Implants are
implanted "to serve as an abutment for dentures or orthodontic appli-
ances, or to serve in fracture fixation." Dorland’s Illustrated Medical
Dictionary 827 (28th ed. 1994). Meredith’s treating physicians did
not cite any of these purposes as even one of the purposes for which
Meredith received the Endosseous Implants. Finally, for the same rea-
son, the fact that the manufacturer designed the Endosseous Implants
that were surgically implanted into Meredith’s mandible as replace-
ments for the root portions of missing natural teeth is of no moment.
The record simply does not support that Meredith received these
implants for such purpose.6
In conclusion, we affirm the district court’s grant of summary judg-
ment in favor of Meredith on reasoning slightly different than the dis-
trict court.
AFFIRMED
6
To the extent the district court concluded that the Endosseous
Implants that were surgically implanted into Meredith’s mandible techni-
cally fell within the meaning of "Dental Implants" as found in Exclusion
26, we reject such a conclusion. As we have explained, under the undis-
puted evidence in this case, the Endosseous Implants that were surgically
implanted into Meredith’s mandible were not "Dental Implants" as that
term is used in Exclusion 26.
