Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_18-cv-04215/USCOURTS-cand-3_18-cv-04215-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1132 E.R.I.S.A.: Employee Benefits

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United States District Court

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

JESSICA A. DEVERS,

Plaintiff,

v.

CARPENTERS HEALTH AND WELFARE 

TRUST FUND FOR CALIFORNIA, et al.,

Defendants.

Case No. 18-cv-04215-EMC 

ORDER DENYING DEFENDANTS’ 

MOTION FOR SUMMARY 

JUDGMENT AND GRANTING 

PLAINTIFF’S MOTION FOR 

JUDGMENT

Docket Nos. 35-36

Plaintiff Jessica Devers has filed suit against two affiliated entities, namely, the Carpenters 

Health & Welfare Trust Fund for California (“Carpenters Trust Fund”) and the Carpenters Funds 

Administrative Office of Northern California, Inc. (“Carpenters AO”). The Carpenters Trust Fund 

and the Carpenters AO shall hereinafter be referred to collectively as “Carpenters.” 

The Carpenters Trust Fund is an employee welfare benefit plan within the meaning of 

ERISA, and the Board of Trustees for the Carpenters Trust Fund has delegated administration of 

benefit claims to the Carpenters AO. Ms. Devers is a beneficiary of the Carpenters Trust Fund. 

Ms. Devers filed the instant ERISA lawsuit against Carpenters after a request for benefits was 

denied. More specifically, Ms. Devers asked that coverage be provided for a prescription drug 

known as Chemet, which she asserts is the only effective way of treating skin lesions she has as a 

result of Grover’s disease. That request for coverage was denied. Ms. Devers now challenges that 

denial.

Currently pending before the Court are two motions: (1) Carpenters’ motion for summary 

judgment pursuant to Federal Rule of Civil Procedure 56 and (2) Ms. Devers’s motion for 

judgment pursuant to Federal Rule of Civil Procedure 52. Having considered the parties’ briefs 

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and accompanying submissions, as well as the oral argument of counsel, the Court hereby 

DENIES Carpenters’ motion and GRANTS Ms. Devers’s.

I. FACTUAL & PROCEDURAL BACKGROUND

The Summary Plan Description (“SPD”) and Rules and Regulations (“R&R”)1for the 

Carpenters Trust Fund can be found at Exhibit 1 to the Price Declaration. 

The SPD notes, in relevant part, as follows:

• “Only the full Board of Trustees is authorized to interpret the Plan. The Board has 

discretion to decide all questions about the Plan, including questions about your 

eligibility for benefits and the amount of benefits payable to you.” Price Decl., Ex. 

1 (SPD at 2).

• “A pre-service claim is a request for authorization of care or treatment that requires 

approval in whole or in part before the care or treatment is obtained (also called 

Utilization Review (‘pre-authorization’ or ‘pre-certification’).” Price Decl., Ex. 1 

(SPD at 81) (emphasis added).

• The purpose of the Utilization Review Program is “to help control increasing health 

care costs by avoiding unnecessary services or services that are more costly than 

others that can achieve the same result.” Price Decl., Ex. 1 (SPD at 56).

• Under the Plan, “prior approval of services is required for the following: . . . 

certain prescription Drugs (must be approved by the Plan’s pharmacy benefit 

manager).” Price Decl., Ex. 1 (SPD at 81) (emphasis in original); see also Price 

Decl., Ex. 1 (SPD at 61) (stating that “[c]ertain drugs require Utilization Review” 

by the pharmacy benefit manager, also known as “PBM”). Express Scripts is the 

Plan’s pharmacy benefit manager (also known as “PBM”). See Price Decl., Ex. 1 

(SPD at 61).

• “Off label use of drugs (for an indication other than described in the FDA approved 

 

1 The Price Declaration refers to the R&R as the “Plan Rules.” See Price Decl. ¶ 4.

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drug label) will be allowed if prior approval is first obtained from the PBM.”2 

Price Decl., Ex. 1 (SPD at 63).

• “To request Utilization Review of a drug, your Physician should call Express 

Scripts . . . .” Price Decl., Ex. 1 (SPD at 63); see also Price Decl., Ex. 1 (SPD at 

82) (stating that “your Physician [should] call Express Scripts . . . to obtain preauthorization for any Drug requiring Utilization Review”).

• “If you disagree with the decision made on your Physician’s request for Utilization 

Review, you may appeal it.” Price Decl., Ex. 1 (SPD at 63).

• Appeals of pre-service claim denials that involve “prescription drugs should go to 

the pharmacy benefit manager (Express Scripts).” Price Decl., Ex. 1 (SPD at 86). 

As part of the review process, “[a] different person will review the appeal than the 

person who originally made the initial adverse benefit determination on the claim,” 

and “[t]he reviewer will not give deference to the initial adverse benefit 

determination.” Price Decl., Ex. 1 (SPD at 86). In addition, “[t]he Board [of 

Trustees for the Carpenters Trust Fund] may grant a personal hearing to receive and 

hear any evidence or argument you believe cannot be presented satisfactorily by 

correspondence.” Price Decl., Ex. 1 (SPD at 86). “If the claim was denied on the 

basis of a medical judgment (such as a determination that the treatment of service 

was not Medically Necessary . . . ), a health care professional who has appropriate 

training and experience in a relevant field of medicine will be consulted.” Price 

Decl., Ex. 1 (SPD at 86). The appeal will be decided “within 30 days of receipt of 

the appeal.” Price Decl., Ex. 1 (SPD at 92) (emphasis omitted).

• “For any claims asserted under the Plan or against the Fund or the denial of a claim 

to which the right to review has been waived, the decision of the Board or its 

designated Appeals Committee with respect to a petition for review is final and 

 

2 For purposes of this order, the Court need not address the lack of any explanation as to what 

factors may be considered by the PBM in determining whether the off-label use should be 

approved.

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binding upon all parties, subject only to any civil action you may bring under 

ERISA. Following issuance of the written decision of the Board on an appeal, 

there is no further right of appeal to the Board or right to arbitration.” Price Decl., 

Ex. 1 (SPD at 87).

In turn, the R&R provides, in relevant part, as follows:

• “The Board of Trustees has the exclusive right and discretion to construe and 

interpret the Plan and is the sole judge of the standard of proof required in any 

claim and the application and interpretation of the Plan. Any dispute as to 

eligibility, type, amount or duration of benefits or any right or claim to payments 

from the Fund will be resolved by the Board or its duly authorized designee under 

and pursuant to the provisions of the Plan and the Trust Agreement, and its decision 

is final and binding upon all parties, subject only to judicial review as may be in 

harmony with federal labor law.” Price Decl., Ex. 1 (R&R, Article 9, § 9.01(a)).

• Prescription drug benefits are addressed in Article 5 of the R&R. See Price Decl., 

Ex. 1 (R&R at 129). Section 5.04 addresses exclusions from prescription drug 

coverage. Of particular note, § 5.04(j) provides that no benefits will be provided 

for “[a]ny Drugs not reasonably necessary for the care or treatment of Illness or 

Injury.” Price Decl., Ex. 1 (R&R, Article 5, § 5.04(j). Section 5.04(l) provides that 

no benefits will be provided for “[m]edications with no federal Food and Drug 

Administration (FDA) approved indications. Off label use of prescriptions (for an 

indication other than described in the FDA approved drug label) will be allowed if 

prior approval is first obtained from the Pharmacy Benefit Manager.” Price Decl., 

Ex. 1 (R&R, Article 5, § 5.04(l)).

It appears that, on November 17, 2017, Ms. Devers (or her doctor) made a request to 

obtain Chemet under the employer welfare benefit plan (i.e., the Carpenters Trust Fund). On 

November 26, 2017, the request for coverage was denied. The denial letter, issued by Express 

Scripts, stated as follows:

As we informed your doctor, we are unable to approve this request 

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for the following reason(s):

• Coverage of the requested medication is provided for acute 

lead poisoning, acute arsenic intoxication/poisoning, or acute 

mercury intoxication/poisoning. Coverage cannot be 

authorized at this time.

In accordance with your plan provisions for drug coverage, a review 

has been performed. The review uses the plan’s rules and is based 

on FDA-approved prescribing and safety information, clinical 

guidelines and uses that are considered reasonable, safe and 

effective. . . .

You or your representative may appeal this decision . . . .

Please send your appeal request in writing to:

ATN: CLINICAL APPEALS DEPARTMENT

EXPRESS SCRIPTS

Price Decl., Ex. 2 (CarpH&WID_000234).3

On December 8, 2017, Ms. Devers lodged an appeal with Express Scripts. In her appeal, 

Ms. Devers explained that she first developed skin lesions in 1995 and that, in 2000, she was 

diagnosed with Grover’s disease, also known as “transient acantholytic dermatosis.” Price Decl., 

Ex. 2 (CarpH&WID_000231). She tried many treatments but none proved effective – e.g., one 

treatment was “very painful” and would provide only “6 to 8 weeks of relief until the lesions 

returned.” Price Decl., Ex. 2 (CarpH&WID_000231). “In 2005, Dr. Paul Dantzig, in conjunction 

with Columbia University, published a paper connecting mercury toxicity with Grover’s disease,” 

Price Decl., Ex. 2 (CarpH&WID_000231), and therefore Ms. Devers tried Chemet as a treatment 

for her skin lesions in 2006. Her skin healed but, “[o]ver time, it became apparent that the healing 

was not permanent” and thus she had to “periodically retreat with Chemet,” approximately 2-4 

times a year. Price Decl., Ex. 2 (CarpH&WID_000231-32). In or about 2012, Ms. Devers also 

used Chemet to treat a skin problem that appeared to be unrelated to Grover’s disease. See Price 

 

3 For purposes of this order, the Court assumes that Express Scripts’s denial clearly communicated 

that it was predicated on the § 5.04(l) exclusion – i.e., that the denial was not in any way 

ambiguous as to its basis. See Price Decl., Ex. 1 (R&R, Article 5, § 5.04(l)) (providing that no 

benefits will be provided for “[m]edications with no federal Food and Drug Administration (FDA) 

approved indications” and “[o]ff label use of prescriptions (for an indication other than described 

in the FDA approved drug label) will be allowed if prior approval is first obtained from the 

Pharmacy Benefit Manager”); see also 29 C.F.R. § 2560.503-1(g)(1) (providing that notification 

of an adverse benefit determination “shall set forth, in a manner calculated to be understood by the 

claimant – (i) The specific reason or reasons for the adverse determination; (ii) Reference to the 

specific plan provisions on which the determination is based;” etc.).

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Decl., Ex. 2 (CarpH&WID_000232) (referring to a “new condition” that “was not Grover[’s] 

disease”). Ms. Devers had a urine test at that time “to see what the Chemet was pulling out” and 

learned that she had a high level of lead. Price Decl., Ex. 2 (CarpH&WID_000232). Ms. Devers 

stated that she “cannot have healthy skin without periodic treatments with Chemet” and indicated 

that she takes the “drug as seldomly as possible to address” the heavy metals in her body (i.e., 

mercury and lead). Price Decl., Ex. 2 (CarpH&WID_000232).

According to Carpenters, Express Scripts received the appeal on December 13, 2017, and 

denied it on December 15, 2017. See Price Decl., Ex. 3 (CarpH&WSuppD_000009). In the 

denial, Express Scripts stated that “[a] panel (consisting of a medical director and two licensed 

clinical pharmacists who were not involved in the prior determination) has reviewed [the] appeal” 

and,

[a]s we informed your doctor, we are unable to approve this request 

for the following reasons(s):

• Coverage of the requested medication is provided for acute 

lead poisoning, acute arsenic intoxication/poisoning, or acute 

mercury intoxication/poisoning. Coverage cannot be 

authorized at this time. The information provided on level 1 

appeal indicates that the [sic] you have an acute exposure to 

mercury and lead in the form of painful skin conditions 

including Grover’s disease. However, this does not meet the 

above conditions for coverage.

In accordance with your plan provisions for drug coverage, a review 

has been performed. The review uses the plan’s rules and is based 

on FDA-approved prescribing and safety information, clinical 

guidelines and uses that are considered reasonable, safe and 

effective. . . .

This is a final and binding decision. Our decision does not reflect 

any view about the medical appropriateness of the medication. The 

ultimate decision on your medical care must be made by you and 

your physician. This appeal decision only determines what, if any, 

of the service or supply is payable under the terms of your plan’s 

benefit.

. . . . Under Section 502(a) of ERISA, you . . . have the right to bring 

a civil action if your final appeal is denied. You should carefully 

review the terms of your Summary Plan Description (SPD) to see if 

there is a specific time within which a civil action must begin.

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Price Decl., Ex. 3 (CarpH&WSuppD_000009).4 

Although the denial of the appeal by Express Scripts indicates that it was issued on

December 15, 2017, it appears that Ms. Devers never received a copy of the denial. For example, 

on December 21, 2017 (i.e., almost a week after the denial of the appeal), Ms. Devers sent an 

email to Carpenters, stating that she was writing to “clarify that I submitted information to you 

regarding coverage of Chemet as part of my appeal to the Trustees. Please add this note to the 

information previously submitted and please proceed with the appeal.” Price Decl., Ex. 2 

(CarpH&WID_000229). Ms. Devers also sent a separate email to Carpenters on December 21, 

2017, stating that “I am hoping that we can talk next week. I need to understand the timing of this 

process and why my next step is if you deny coverage.” Price Decl., Ex. 2 

(CarpH&WID_000205) (emphasis added). Finally, Ms. Devers sent an email to Carpenters on 

January 3, 2018, noting that she would be sending information from her doctor’s office5and 

providing other information from her pharmacist, which she asked to be “add[ed] . . . to my 

appeal.” Price Decl., Ex. 2 (CarpH&WID_000202). These emails all indicate that Ms. Devers 

was under the impression that her appeal was still pending (i.e., had not been denied). 

Moreover, the record suggests that Carpenters did not receive a copy of Express Scripts’s 

denial of the appeal either. Notably, Carpenters did not initially provide a copy of the denial of the 

appeal to Ms. Devers as part of the administrative record. See Price Decl. ¶ 5 (noting that Exhibit 

2 is the administrative record which was provided as part of the initial disclosures; Express 

Scripts’s denial of the appeal is found in Exhibit 3). According to Carpenters, in March 2019, 

when a mediation was taking place during this litigation, it noticed for the first time that 

 

4 As above, for purposes of this order, the Court assumes that Express Scripts’s denial clearly 

communicated that it was predicated on the § 5.04(l) exclusion.

Also, for purposes of this order, the Court assumes that Express Scripts denied the appeal 

for reasons beyond the mere fact that the use was off label. If Express Scripts could deny prior 

approval simply because a use was off label, then there would no reason to have a provision in the 

plan stating that off-label use would require prior approval.

5 Ms. Devers’s doctor’s office provided a letter dated January 3, 2018, from a nurse practitioner 

(as the treating physician had passed away), stating that Ms. Devers “requires Chemet for her 

medical care. She tried many additional and alternative treatments over many years, before Dr. 

Dantzig published his research. There is no other treatment that is effective in controlling her 

Grover’s disease.” Price Decl., Ex. 2 (CarpH&WID_000200).

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there was no documentation that Express Scripts . . . had received or 

heard an appeal on Ms. Devers’ initial claim. There was also no 

record of Express Scripts processing or ruling on an appeal by Ms. 

Devers in The Fund’s files. I thought this was odd, given the fact 

that Express Scripts was given the authority under the Plan Rules to 

process and make decisions regarding claims and appeals of denial 

of prescription drug benefits under the Plan. I therefore requested 

that Express Scripts send us any and all documents (if any) they had 

regarding an appeal Ms. Devers made after they denied the claim in 

this case.

Express Scripts forwarded to the Fund Office documents pertaining 

to an appeal that Ms. Devers filed after her initial claim was denied. 

. . . The decision denying the appeal and the reasons for that denial 

was [sic] sent only to Ms. Devers and her doctor. The Fund did not 

have copies of the appeal decision in its custody when it proceeded 

to hear Ms. Devers[’s] appeal on January 11, 2018.

Price Decl. ¶ 6.

On January 11, 2018 (i.e., several weeks after the December 15 denial of the appeal by 

Express Scripts), a hearing panel for the Carpenters Trust Fund held a hearing on Ms. Devers’s 

appeal. See Price Decl., Ex. 2 (CarpH&WID_000175). Then, on the same day, the Carpenters 

AO issued a letter regarding the appeal, stating as follows:

The Trustees have carefully considered all the comments, 

documents, records and other information provided and applied the 

terms of the Plan that apply to your request for review. For the 

reasons set out below, the Trustees have determined that the benefits 

being requested are not covered by the Plan, and accordingly, the 

decision following review is that your request for Request [sic] to 

obtain prescription drug, Chemet must be denied, subject to 

reconsideration.

Specific Reason for Denial

No benefits will be provided for any Drugs not reasonably necessary 

for the care and treatment of illness or injury.

Applicable Plan Provisions

5.04.j, Plan A[6]

. . . .

This decision on review is the Plan’s final decision. You have the 

right to bring a civil action under ERISA Section 502(a) provided 

 

6 As noted above, § 5.04(j) provides that no benefits will be provided for “[a]ny Drugs not 

reasonably necessary for the care or treatment of Illness or Injury.” Price Decl., Ex. 1 (R&R, 

Article V, § 5.04(j)).

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civil action is taken within two years of the date of this benefit 

denial.

Price Decl., Ex. 2 (CarpH&WID_000190).

In July 2018, Ms. Devers initiated the instant action.

II. DISCUSSION

A. Legal Standard

As an initial matter, the Court bears in mind that it has two different procedural motions 

before it: (1) Carpenters’ motion for summary judgment pursuant to Rule 56 and (2) Ms. Devers’s 

motion for judgment pursuant to Rule 52.

Rule 56 provides that a “court shall grant summary judgment if the movant shows that 

there is no genuine dispute of material fact and the movant is entitled to judgment as a matter of 

law.” Fed. R. Civ. P. 56(a). An issue of fact is genuine only if there is sufficient evidence for a 

reasonable jury to find for the nonmoving party. See Anderson v. Liberty Lobby, Inc., 477 U.S. 

242, 248-49 (1986). “The mere existence of a scintilla of evidence . . . will be insufficient; there 

must be evidence on which the jury could reasonably find for the [nonmoving party].” Id. at 252. 

At the summary judgment stage, evidence must be viewed in the light most favorable to the 

nonmoving party and all justifiable inferences are to be drawn in the nonmovant’s favor. See id. at 

255. Where a defendant moves for summary judgment on a claim for which the plaintiff has the 

burden of proof, the defendant may prevail simply by pointing to the plaintiff's failure “to make a 

showing sufficient to establish the existence of an element essential to [the plaintiff's] case.”

Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986).

Rule 52 concerns, inter alia, findings and conclusions by a court in the context of a bench 

trial. It provides in relevant part as follows: “In General. In an action tried on the facts without a 

jury or with an advisory jury, the court must find the facts specially and state its conclusions of 

law separately.” Fed. R. Civ. P. 52(a)(1). In Kearney v. Standard Insurance Co., 175 F.3d 1084 

(9th Cir. 1999), the Ninth Circuit indicated that, where there is an ERISA dispute, a trial based on 

the administrative record alone may be conducted. That is, 

the district court may try the case on the record that the 

administrator had before it. This is vastly less expensive to all 

parties, accomplishes the policies enacted as part of the statute, and 

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also gives significance, which would otherwise largely evaporate, to 

the administrator’s internal review procedure required by the statute.

Id. at 1095; see also id. at 1094 (stating that “[a] full trial de novo in any ERISA dispute where 

there was a genuine dispute of fact as to whether the individual qualified for a benefit would 

undermine” the policies underlying ERISA; “[t]he means that suggests itself for accomplishing 

trial of disputed facts, while preserving the value of the fiduciary review procedure, keeping costs 

and premiums down, and minimizing diversion of benefit money to litigation expense, is trial on 

the administrative record, in cases where the trial court does not find it necessary under Mongeluzo

to consider additional evidence”).7 “In a trial on the record, but not on summary judgment, [a] 

judge can evaluate the persuasiveness of conflicting testimony and decide which is more likely 

true.” Id. at 1095. 

B. Standard of Review

Whether the Court is considering Carpenters’ summary judgment motion or Ms. Devers’ 

request for a trial based on the administrative record, the parties agree that the Court evaluates 

Carpenters’ substantive decision to deny benefits for an abuse of discretion. See Defs.’ Mot. at 4 

(noting the parties’ “stipulat[ion] that the District Court in this case should use the abuse of 

discretion standard in reviewing the decision that Defendants reached in denying Plaintiff’s claim 

for the drug”). 

Under this deferential standard, a plan administrator's decision “will 

not be disturbed if reasonable.” This reasonableness standard 

requires deference to the administrator's benefits decision unless it is 

“(1) illogical, (2) implausible, or (3) without support in inferences 

that may be drawn from the facts in the record.”

Stephan v. Unum Life Ins. Co. of Am., 697 F.3d 917, 929 (9th Cir. 2012). There is also an abuse 

of discretion if a decision is rendered “without any explanation.” Johnson v. Trs. of W. 

Conference of Teamsters Pension Tr. Fund, 879 F.2d 651, 654 (9th Cir. 1989).

The above applies where an ERISA plaintiff is challenging a substantive decision to deny. 

However, an ERISA plaintiff may also claim an abuse of discretion based on the failure of a plan 

 

7

In Mongeluzo, the Ninth Circuit “held . . . that the district court had discretion to allow evidence 

that was not before the plan administrator ‘only when circumstances clearly establish that 

additional evidence is necessary to conduct an adequate de novo review.’” Kearney, 175 F.3d at 

1090.

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or plan administrator to follow applicable procedures as provided for under ERISA. See Abatie v. 

Alta Health & Life Ins. Co., 458 F.3d 955, 959 (9th Cir. 2006) (stating that, “when a decision by 

an administrator utterly fails to follow applicable procedures, the administrator is not, in fact, 

exercising discretionary powers under the plan, and its decision should be subject to de novo 

review,” but “[l]esser irregularities . . . do not remove the decision from abuse of discretion 

review”), abrogated on other grounds by Metro Life Ins. Co. v. Glenn, 554 U.S. 105 (2008). Cf.

Dimery v. Reliance Standard Life Ins. Co., 597 F. App’x 408, 409 (9th Cir. 2015) (stating that 

“ERISA procedural violations do not alter the standard of review unless the violations cause the 

beneficiary substantive harm”); Gatti v. Reliance Std. Life Ins., 415 F.3d 978, 985 (9th Cir. 2005) 

(stating that “procedural violations of ERISA do not alter the standard of review unless those 

violations are so flagrant as to alter the substantive relationship between the employer and 

employee, thereby causing the beneficiary substantive harm”). For a procedural violation, a 

remand to the plan is the typical remedy. See Chuck v. Hewlett Packard Co., 455 F.3d 1026, 1035 

(9th Cir. 2006) (stating that “the usual remedy for a violation of § 1133 [which governs claims 

procedure] is ‘to remand to the plan administrator so the claimant gets the benefit of a full and fair 

review’”).

C. Reason for Denial of Ms. Devers’s Claim for Benefits

The threshold dispute between the parties is why Ms. Devers’s claim for benefits was 

denied on appeal, thus raising the question which body issued the final decision.

• According to Ms. Devers, her appeal was denied because Carpenters determined 

that Chemet was not a medical necessity, as the Trustees found on January 11, 

2018. See Price Decl., Ex. 1 (R&R, Article 5, § 5.04(j)) (providing that no benefits 

will be provided for “[a]ny Drugs not reasonably necessary for the care or 

treatment of Illness or Injury”); the final decision was issued by the hearing panel 

for the Carpenters Trust Fund.

• According to Carpenters, the appeal was denied because Ms. Devers’s use of 

Chemet was “off label,” and, on December 15, 2017, Express Scripts (on behalf of 

Carpenter) did not give prior approval to the off-label use. See Price Decl., Ex. 1 

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(R&R, Article 5, § 5.04(l)) (providing that no benefits will be provided for 

“[m]edications with no federal Food and Drug Administration (FDA) approved 

indications” and “[o]ff label use of prescriptions (for an indication other than 

described in the FDA approved drug label) will be allowed if prior approval is first 

obtained from the Pharmacy Benefit Manager”). Carpenters thus contends Express 

Scripts rendered the final decision.

In sum, Ms. Devers deems the final decision of Carpenters to be the Trustees’ denial of her appeal 

on January 11, 2018, whereas Carpenters argues that the Trustees’ denial should, in effect be 

ignored, given that Express Scripts issued its final denial of the appeal several weeks earlier on 

December 15, 2017.

The Court rejects Carpenters’ position. Even assuming that Ms. Devers’s appeal would 

ordinarily have been decided by Express Scripts, see Price Decl., Ex. 1 (SPD at 86) (stating that 

appeals of pre-service claim denials – where the claim involves prescription drug benefits –

“should go to the pharmacy benefit manager (Express Scripts)”), the Trustees (for whatever 

reason) did not find out about Express Scripts’s denial of the appeal and, instead of instructing 

Express Scripts to rule on Ms. Devers’s appeal, decided to address the appeal themselves – as they

were entitled to do under the SPD and R&R. See, e.g., Price Decl., Ex. 1 (SPD at 86) (providing 

that “[t]he Board may grant a personal hearing to receive and hear any evidence or argument you 

believe cannot be presented satisfactorily by correspondence”); Price Decl., Ex. 1 (SPD at 2) 

(providing that “[t]he Board has discretion to decide all questions about the Plan, including 

questions about your eligibility for benefits and the amount of benefits payable to you”); Price 

Decl., Ex. 1 (R&R, Article 9, § 9.01(a)) (providing that “[a]ny dispute as to eligibility, type, 

amount or duration of benefits or any right or claim to payments from the Fund will be resolved 

by the Board or its duly authorized designee under and pursuant to the provisions of the Plan and 

the Trust Agreement”). Therefore, only evidence that was considered by the Trustees, as the 

ERISA decisionmaker, counts as being part of the administrative record. See Kearney, 175 F.3d at 

1090-91 (stating that, “[i]f a court reviews the administrator’s decision, whether de novo . . . or for 

abuse of discretion, the record that was before the administrator furnishes the primary basis for 

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review”). Here, the Trustees, as the ERISA decisionmaker, did not consider Express Scripts’s 

denial of the appeal (indeed, did not even know about it at the relevant time), and thus Express 

Scripts’s denial of the appeal cannot be a part of the administrative record. In short, Express 

Scripts’s denial of Ms. Devers’s appeal is immaterial and her appeal was ultimately denied by the 

Trustees based on the Trustees’ finding that Chemet was not a medical necessity (i.e., Ms. 

Devers’s position). Only the Trustees’ decision is subject to review herein.

D. Medical Necessity

The Court now turns to the issue of whether the Trustees’ decision was reasonable. See 

Stephan, 697 F.3d at 929 (stating that the “reasonableness standard requires deference to the 

administrator’s benefits decision unless it is ‘(1) illogical, (2) implausible, or (3) without support 

in inferences that may be drawn from the facts in the record’”). Under the ERISA regulations, 

where there is an “adverse benefit determination by a group health plan” and the “determination is 

based on a medical necessity . . . exclusion or limit,” “either an explanation of the scientific or 

clinical judgment for the determination, applying the terms of the plan to the claimant’s medical 

circumstances, or a statement that such explanation will be provided free of charge upon request” 

is required. 29 C.F.R. § 2560.503-1(g)(1)(v)(B). The SPD contains a similar provision. See also

Price Decl., Ex. 1 (SPD at 85) (providing that “the specific reason(s) for the [adverse benefit] 

determination” must be provided; also providing that, “if the determination was based on the 

absence of medical necessity . . . , a statement that an explanation of the scientific or clinical 

judgment for the determination is available upon written request at no charge”). 

In the instant case, the Trustees’ denial of the appeal did not provide an explanation of the 

scientific or clinical judgment for the determination as required by law and the SPD.

8

 Such a 

substantial procedural violation constitutes an abuse of discretion, see Abatie, 458 F.3d at 959, for 

which remand would normally be warranted. See Chuck, 455 F.3d at 1035. However, the Court 

 

8 While the denial of the appeal did state, in general terms, that “[y]ou are entitled to receive, upon 

request and free of charge, reasonable access to, and copies of, all documents, records, and other 

information relevant to your claim for benefits,” Price Decl., Ex. 2 (CarpH&WID_000190), the 

denial did not specifically state that Ms. Devers could get a copy of the explanation of the 

scientific or clinical judgment for the determination. 

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sees no value in remanding to the plan given the specific circumstances at hand. More 

specifically, there is no evidence in the record upon which the Trustees could rely to support a 

ruling against Ms. Devers. There is nothing in the administrative record to support the conclusion 

of no medical necessity. On the other hand, the record contains concrete evidence supporting Ms. 

Devers’s position that Chemet was in fact medically necessary. This includes the Dantzig paper 

connecting mercury toxicity with Grover’s disease; the results of a urine test (indicating a high 

level of heavy metals); a letter from Ms. Devers’s doctor’s office stating that “[t]here is no other 

treatment [i.e., other than Chemet] that is effective in controlling [Ms. Devers’s] Grover’s 

disease,” Price Decl., Ex. 2 (CarpH&WID_000200); and the plan’s prior coverage of Chemet. 

Based on the record, the Trustees’ finding that Chemet was not a medical necessity was 

unreasonable whether under de novo or abuse of discretion review. Ms. Devers is thus entitled to 

benefits under the plan. 

The Court orders the parties to meet and confer to see if they can reach agreement on the 

exact award of benefits due under the plan. During the meet and confer, the parties should also 

discuss the issue of attorney’s fees. Finally, during the meet and confer, the parties should discuss 

injunctive relief. The Court notes that, although Ms. Devers requested an injunction at the hearing 

with respect to her claim for breach of fiduciary duty (and the Court indicated its inclination to 

grant relief), her motion did not expressly address the claim for breach of fiduciary duty nor did 

expressly request injunctive relief. See, e.g., Pl.’s Mot. at 13 (asking “for an award of benefits” as 

well as “prejudgment interest, attorneys fees and costs,” but not mentioning injunctive relief). 

Moreover, to the extent Ms. Devers is simply asking for an order requiring Carpenters to comply 

with ERISA and its regulations (as she stated at the hearing), “obey-the-law” injunctions are 

generally disfavored. See, e.g., EEOC v. AutoZone, Inc., 707 F.3d 824, 841-42 (7th Cir. 2013)

(discussing concerns with “[a]n injunction that does no more than order a defeated litigant to obey 

the law” – e.g., overbreadth and vagueness, although adding that such an injunction may be 

appropriate in certain circumstances, for instance, “where the evidence suggests that the proven 

illegal conduct may be resumed”). 

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III. CONCLUSION

For the foregoing reasons, the Court denies Carpenters’ motion for summary judgment and 

grants Ms. Devers’s motion for judgment. With respect to Ms. Devers’s motion, the necessary 

findings of fact and conclusions of law are embedded in the discussion above; however, for the 

sake of clarity, the Court reiterates as follows.

• Carpenters ultimately denied coverage based on lack of medical necessity.

• Carpenters’ decision failed to comply with 29 C.F.R. § 2560.503-1(g)(1)(v)(B) and 

the SPD.

• There is no evidence in the administrative record to support a lack of medical 

necessity. In contrast, the only evidence in the administrative record establishes 

that Chemet was medically necessary for Ms. Devers.

• The Court therefore holds that Carpenters erred, under either de novo review or 

review for abuse of discretion, in denying coverage for Chemet.

• Ms. Devers is entitled to benefits.

As discussed above, the parties are to meet and confer to address remaining issues. The 

parties shall report back on their meet and confer within three weeks of the date of this order.

This order disposes of Docket Nos. 35 and 36.

IT IS SO ORDERED.

Dated: August 7, 2019

______________________________________

EDWARD M. CHEN

United States District Judge

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