Court Opinion

ID: 1038334
Source: CourtListenerOpinion
Date Created: 2013-08-24 00:02:43.073197+00
Date Added: 2024-06-11T09:18:32.409001
License: Public Domain

Case: 12-15400      Date Filed: 08/22/2013      Page: 1 of 5

                                                                    [DO NOT PUBLISH]

                 IN THE UNITED STATES COURT OF APPEALS

                           FOR THE ELEVENTH CIRCUIT

                             _________________________
                                    No. 12-15400
                             _________________________

                         D.C. Docket No. 1:11-cv-00010-WLS

CORNELIUS B. FAISON,

                                                                         Plaintiff-Appellee,

                                           versus

DONALSONVILLE HOSPITAL INC.,

                                                                     Defendant-Appellant.

                             _________________________
                     Appeal from the United States District Court
                         For the Middle District of Georgia
                          _________________________
                                 (August 22, 2013)

Before MARTIN and BLACK, Circuit Judges, and GOLDBERG, ∗ Judge.

PER CURIAM:

∗
 Honorable Richard W. Goldberg, United States Court of International Trade Judge, sitting by
designation.
              Case: 12-15400     Date Filed: 08/22/2013    Page: 2 of 5

      Cornelius Faison (Faison) sued Donalsonville Hospital, Inc. (the Hospital),

pursuant to the Employee Retirement Income Security Act of 1974 (ERISA), to

recover insurance benefits the Hospital had denied as excluded from coverage.

After a bench trial on the papers, the district court granted Faison’s Motion for

Entry of Judgment. After careful consideration of the record, and with the benefit

of oral argument, we affirm.

                                          I.

      The Hospital has an Employee Benefit Plan, which includes health insurance

coverage (the Plan). The Hospital is the Plan Administrator. According to the

Plan, in this capacity, the Hospital has “maximum legal discretionary authority to

construe and interpret the terms and provisions of the Plan, to make determinations

regarding issues which relate to eligibility for benefits.” Paragon Benefits, Inc.

(Paragon) is a third-party administrator of the Plan. In this role, Paragon is

responsible for receiving claims from covered individuals and making an initial

claim determination.

      When Paragon’s initial benefits decision is appealed, the Hospital, as

fiduciary of the Plan, reviews the determination, without giving Paragon’s decision

any deference. The Hospital’s Benefits Committee (Committee) makes the final

determination on appeals. The members of the Committee are Herman Brookins,

Charles Orrick, and James Moody.

                                          2
              Case: 12-15400     Date Filed: 08/22/2013    Page: 3 of 5

      The Plan includes a number of exclusions. As relevant to this case, the Plan

excludes from coverage:

         (19) Illegal acts. Charges for services received as a result of
         Injury or Sickness occurring directly or indirectly, as a result
         of a Serious Illegal Act, or a riot or public disturbance. For
         purposes of this exclusion, the term “Serious Illegal Act” shall
         mean any act or series of acts that, if prosecuted as a criminal
         offense, a sentence to a term of imprisonment in excess of one
         year could be imposed. It is not necessary that criminal
         charges be filed, or, if filed, that a conviction result, or that a
         sentence of imprisonment for a term in excess of one year be
         imposed for this exclusion to apply. Proof beyond a
         reasonable doubt is not required.
      The Hospital funds the Plan from its own revenue, plus a modest

contribution from the employees. The Hospital’s annual funding for benefits

provided by the Plan is approximately $2,300,000.00. The funds are considered by

Hospital management to be Hospital assets. The Hospital purchases reinsurance

for claims exceeding $50,000.

       On July 26, 2009, Faison sustained serious injuries after he crashed his

motorcycle into a tree while eluding a Georgia State Patrol Officer. As a result of

his accident, Faison was in the hospital for over a month and amassed over

$480,000 in medical bills.

      As a result of his conduct leading to the accident, Faison was charged with:

(1) fleeing/attempting to elude; (2) speeding (120 plus); (3) failing to maintain

lane; (4) driving with an expired tag; and (5) violating his permit. Considering

                                          3
               Case: 12-15400     Date Filed: 08/22/2013    Page: 4 of 5

each charge independently, none of the charges could result in a sentence to a term

of imprisonment in excess of one year. See O.C.G.A. § 17-10-3(a)(1)

(misdemeanors punishable by maximum 12 months); O.C.G.A. § 40-6-1 (unless

otherwise specified, it is a misdemeanor to do any act forbidden in this chapter);

O.C.G.A. §§ 40-2-8 (expired tag), 40-5-30 (permit), 40-6-48 (failure to maintain

lane), 40-6-181 (speeding), 40-6-395 (fleeing). Faison pleaded guilty to each

charge. He was sentenced to 12 months of probation on each charge, to be served

consecutively.

      At this time, Faison was a plan participant of the Plan. As required by the

Plan, Faison submitted his claim to Paragon. Paragon denied his request for

coverage. Faison appealed the denial to the Hospital. The Hospital sent a letter to

Faison on October 21, 2010, which explained that the Committee affirmed the

denial of Faison’s claim, based on the Illegal Acts exclusion in the Plan.

                                               II.

      The parties consented to have the district court hear their case as a trial on

the papers pursuant to Federal Rule of Civil Procedure 52. In accordance with that

rule, the district court issued an opinion explaining its findings of fact and

conclusions of law separately.

      “We review de novo a district court’s ruling affirming or reversing a plan

administrator’s ERISA benefits decision, applying the same legal standards that

                                           4
               Case: 12-15400     Date Filed: 08/22/2013   Page: 5 of 5

governed the district court’s decision.” Blankenship v. Metro Life. Ins. Co., 644

F.3d 1350, 1354 (11th Cir. 2011). “Review of the plan administrator’s denial of

benefits is limited to the material available to the administrator at the time it made

its decision.” Id. Blankenship sets forth a six-step test for reviewing a plan

administrator’s benefits decision. Id. at 1355.

      “We review for clear error factual findings made by a district court after a

bench trial.” Morrissette-Brown v. Mobile Infirmary Med. Ctr., 506 F.3d 1317,

1319 (11th Cir. 2007). “A factual finding is clearly erroneous when although there

is evidence to support it, the reviewing court on the entire evidence is left with the

definite and firm conviction that a mistake has been committed.” Id. (quotation

marks omitted).

      After applying these legal standards and considering only those arguments

that were actually made by the parties in the district court, see e.g., Depree v.

Thomas, 946 F.2d 784, 793 (11th Cir. 1991) (“[A]n issue not raised in the district

court and raised for the first time in an appeal will not be considered by this

court.”), we AFFIRM.

                                           5