Court Opinion

ID: 6929173
Source: CourtListenerOpinion
Date Created: 2022-07-23 23:48:06.012374+00
Date Added: 2024-06-11T16:07:04.284792
License: Public Domain

SEYMOUR, Circuit Judge,
dissenting in part.
After reviewing the relevant Plan provisions, I regret that I am unable to agree with the majority’s conclusion in section l.a. regarding maternity expense benefits, although I agree fully with the rest of the majority opinion.
This court held in Torix v. Ball Corp., 862 F.2d 1428, 1429 (10th Cir.1988), that a Plan administrator’s decision is arbitrary and capricious if it does not represent a reasonable interpretation of the Plan’s terms. We concluded that the denial of benefits there was unreasonable because it was based on an unduly restrictive interpretation that severely undermined the policy concerns underlying ERISA. In my judgment, not only is defendants’ interpretation here unduly restrictive, the plain language of the Plan simply does not permit defendants’ construction of it. Accordingly, I agree with the district court that defendants’ interpretation is unreasonable, and therefore arbitrary and capricious under Torix.
The Maternity Expense Benefit provision in the Plan states that it will'pay “any of the charges described in (1) and (2) ... up to the maximum as set forth in the Schedule of Benefits.” Section (1) in turn provides that the Plan will pay the “fee charged by a *1573Physician for obstetrical procedures [plural],” and section (2) states that the Plan will pay the “charge made by the Hospital for Room and Board and all other services for medical care and treatment.” These provisions on their face state that the costs of multiple services and procedures will be paid up to the maximum set out in the Schedule of Benefits. Although that Schedule sets a maximum benefit for each of two different procedures, it does not state that only one of these procedures will be covered per pregnancy.
The analogy to the birth of twins by the same birth method is not helpful because the policy clearly limits the total payment when there is one birth method, regardless of the number of babies delivered. Moreover, delivering two children by the same method would certainly be far less costly than having to use two different procedures. In view of the Plan language covering multiple services and procedures and the lack of any language restricting that coverage, I cannot agree that defendants’ interpretation is reasonable. I would therefore affirm the district court on this issue.