Court Opinion

ID: 2963570
Source: CourtListenerOpinion
Date Created: 2015-09-21 21:12:11.789024+00
Date Added: 2024-06-11T11:42:42.504911
License: Public Domain

USCA1 Opinion

	

          July 19, 1995         [NOT FOR PUBLICATION]

                            UNITED STATES COURT OF APPEALS
                                FOR THE FIRST CIRCUIT
                                                     
                                 ____________________

        No. 94-1754

                     FLORENCE NIGHTINGALE NURSING SERVICES, INC.,

                                Plaintiff, Appellant,

                                          v.

                         PAUL REVERE LIFE INSURANCE COMPANY,

                                 Defendant, Appellee.

                                                     
                                 ____________________

                     APPEAL FROM THE UNITED STATES DISTRICT COURT

                          FOR THE DISTRICT OF MASSACHUSETTS

                   [Hon. Nathaniel M. Gorton, U.S. District Judge]
                                              ___________________

                                                     
                                 ____________________

                               Torruella, Chief Judge,
                                          ___________

                            Bownes, Senior Circuit Judge,
                                    ____________________

                               and Cyr, Circuit Judge.
                                        _____________

                                                     
                                 ____________________

             William J. McLeod for appellant.
             _________________
             David  A. Talman, with whom Phillips, Silver, Talman & Aframe was
             ________________            _________________________________
        on brief for appellee.

                                                     
                                 ____________________

                                                     
                                 ____________________

                    Per  Curiam.   Plaintiff  Florence  Nightingale Nursing
                    Per  Curiam.
                    ___________

          Services,  Inc. ("Nightingale")  appeals  from  a district  court

          judgment summarily  disallowing its  claim for benefits  under an

          Employee Retirement  Income  Security Act  ("ERISA")  health  and

          welfare  plan  ("Plan")  issued  by defendant  Paul  Revere  Life

          Insurance  Co. ("Revere").   As  summary judgment was  proper, we

          affirm. 

                                          I
                                          I

                                      BACKGROUND
                                      BACKGROUND
                                      __________

                    On May  15, 1989, James Thoumes,  M.D., notified Revere

          that  its insured,  Herbert Striesfield,  would require  "Private

          Duty Licensed nursing care  for . . . Acquired  Immune Deficiency

          Syndrome."  Doctor Thoumes explicitly informed Revere that it was

          "medically necessary"  that Striesfield receive "a  minimum of 12

          hours daily [nursing] care at his home," in administering medica-

          tions and  safeguarding him from  injury which might  result from

          his unsteady gait and poor balance. 

                    Nightingale  provided  the prescribed  nursing services

          after obtaining  a valid assignment of  Striesfield's Revere Plan

          benefits and after requesting Revere to verify the substance of a

          telephone conversation in which, according to Nightingale, Revere

          had 

                    confirmed and authorized the  following bene-
                    fits, coverage and payment to [Nightingale] .
                    . . for Herbert Striesfield's nursing care:

                         (1)  Unlimited skilled nursing care.

                         (2)  Payment to  [Nightingale] for nurs-

                                          2

                              ing care provided  upon receipt  of
                              our  invoice will  be paid  at 100%
                              for fees incurred.

                    [Nightingale]  understand[s]  that [its]  in-
                    voice must  be  attached to  a  physician[']s
                    Letter  of  Medical  Necessity  ordering  the
                    nursing care required and  nursing documenta-
                    tion.

          The record contains no response from Revere.

                    Later,  Nightingale asked  Revere  to  confirm  another

          telephone  conversation in  which,  according  to Nightingale,  a

          responsible Revere  employee had "stated that  [Revere] would pay

          for  C.N.A.s [i.e.,  certified nurses  aides]."   Nightingale re-

          quested a response within  five days in the event there  were any

          discrepancies between its letter and Revere's understanding as to

          the substance of the putative telephone conversation.  The record

          contains no response from Revere.

                    Under the  heading "What We  Do Not Pay,"  the relevant

          Plan language provided: 

                    16.  Any  service,  supply or  treatment con-
                    nected with  custodial care.   We do  not pay
                    for these services or supplies no  matter who
                    provides, prescribes,  recommends or performs
                    them.   Custodial care means service designed
                    to  help family  members  meet  the needs  of
                    daily living  whether  they are  disabled  or
                    not.  These services include help in:

                         a.   walking  or getting  in and  out of
                              bed;

                         b.   personal  care   such  as  bathing,
                              dressing, eating  or preparing spe-
                              cial diets; or

                         c.   taking medications which the family
                              member  would  normally be  able to
                              take without help.

                                          3

                                          4

          The summary  judgment record discloses that  the nursing services

          provided by Nightingale included:   feeding Striesfield, monitor-

          ing  his diet, making him comfortable,  moving his extremities to

          improve muscle tone, massage,  and assisting him to and  from the

          bathroom.

                    Early on, Revere  disbursed $3,250.00 in  Plan benefits

          to Nightingale.  Thereafter, however, in  reliance on the "custo-

          dial  care" exclusion, supra at  p. 3, Revere  denied all further
                                 _____

          claims based on Nightingale's nursing services to Striesfield. 

                    Nightingale  eventually  brought  suit  in  the  United

          States District Court  for the District of  Massachusetts.  After

          the case  was referred  to a magistrate  judge, see  28 U.S.C.   
                                                          ___

          636(b)(1)(B) (1995),  Revere moved for summary  judgment based on

          the  "custodial care"  exclusion.   Nightingale filed  its cross-

          motion for summary judgment and an opposition to Revere's summary

          judgment motion,  asserting that  the "custodial  care" exclusion

          was "vague and ambiguous"  and that Revere's oral representations

          to Nightingale estopped Revere from denying coverage.  

                    The magistrate judge  recommended summary judgment  for

          Revere on the grounds that coverage was plainly foreclosed by the

          "custodial care"  exclusion and that Nightingale's estoppel claim

          was  not cognizable  because the  alleged oral  representation or

          informal writing upon which it relied could not be used to modify

          the unambiguous  terms of  the Plan.    Nightingale filed  timely

          objection  to the  magistrate-judge's report  and recommendation.

          In due course, the  district court adopted the report  and recom-

                                          5

          mendation and Nightingale appealed.

                                          II
                                          II

                                      DISCUSSION
                                      DISCUSSION
                                      __________

          A.   Standard of Review
          A.   Standard of Review
               __________________

                    Summary  judgment  rulings  are  reviewed  de  novo  to
                                                               __  ____

          determine whether the  pleadings, depositions, answers to  inter-

          rogatories, and admissions on file, together with the affidavits,

          if any,  show there is no  genuine issue as to  any material fact

          and the  moving party is entitled to judgment as a matter of law.

          Simon v. FDIC, 48 F.3d  53, 56 (1st Cir. 1995).   The evidence is
          _____    ____

          reviewed  in  the light  most  favorable to  the  party resisting

          summary judgment.  Id.
                             ___

          B.   Plan Benefits
          B.   Plan Benefits
               _____________

                    "[A] denial of benefits  challenged under [29 U.S.C.]  

          1132(a)(1)(B) is to be  reviewed under a de novo  standard unless
                                                   __ ____

          the benefit plan gives the administrator or fiduciary discretion-

          ary authority to  determine eligibility for  benefits or to  con-

          strue the terms of the  plan."  Firestone Tire and Rubber  Co. v.
                                          ______________________________

          Bruch, 489  U.S. 101, 115  (1989).  As  the Revere Plan  vests no
          _____

          such  discretion  in  the  Plan administrator  or  fiduciary,  we

          conduct plenary review. 

               1.   "Private Duty Nursing"
               1.   "Private Duty Nursing"
                     ____________________

                    The   Plan  provides  that  "reasonable  and  customary

          charges" shall be covered for "[m]edically necessary private duty

          nursing  ordered  by the  attending doctor  to  be provided  by a

          licensed registered  or licensed practical nurse."   Although the

                                          6

          Plan  does not define the term, Nightingale argues on appeal that

          a genuine issue of material fact exists as to whether the servic-

          es provided Striesfield constituted "private duty nursing."  

                    This  argument  was  asserted  for the  first  time  in

          Nightingale's  objection  to  the  magistrate-judge's  report and

          recommendation.   It  was accompanied  by evidence  purporting to

          show that the nursing services provided to Striesfield "included"

          services which  a reasonable  factfinder could  consider "private

          duty nursing."   As a general  rule, parties are not  entitled to

          plenary review  of arguments  never raised before  the magistrate

          judge  designated  to  hear  and report  on  dispositive  motions

          pursuant to 28 U.S.C.   636(b)(1)(B).  Paterson-Leitch  Co., Inc.
                                                 __________________________

          v.  Massachusetts Mun. Wholesale Elec.  Co., 840 F.2d 985, 990-91
              _______________________________________

          (1st  Cir. 1988)  ("We  hold categorically  that an  unsuccessful

          party  is not entitled as of right to de novo review by the judge
                                                __ ____

          of an argument never  seasonably raised before the magistrate.").

          Although  the district  court did  not  explicitly rule  upon the

          belated argument  relating to  the meaning  of the  term "private

          duty nursing,"  we find no abuse  of discretion.  See  id. at 991
                                                            ___  ___

          (finding no abuse  of discretion in district  court's decision to

          deny "another nibble at this particular apple" where party failed

          to present its claim to magistrate judge in first instance).

                    In all events, however,  the sole evidentiary underpin-

          ning  for  the  unpreserved argument  advanced  on  appeal  is an

          affidavit  reviewing the patient  file Nightingale  maintained on

          Striesfield.  The affidavit does not specify the types of nursing

                                          7

          services  provided by  Nightingale,  nor  otherwise reveal  which

          nursing services, if any,  might constitute covered "private duty

          nursing."  The burden  of producing competent evidence sufficient

          to  demonstrate a trialworthy issue  as to whether the particular

          services rendered were covered  within the "private duty nursing"

          provision  lay  with  Nightingale.   See  McCarthy  v.  Northwest
                                               ___  ________      _________

          Airlines, Inc.,  No. 94-2282,  slip op.  at 2 (1st  Cir. May  31,
          ______________

          1995) (party resisting summary  judgment on issue as to  which it

          bears  ultimate  burden of  proof  "must  affirmatively point  to

          specific  facts that  demonstrate the  existence of  an authentic

          dispute."); Garside v. Osco Drug, Inc., 895 F.2d 46, 48 (1st Cir.
                      _______    _______________

          1990) (same).   As the  Nightingale affidavit failed  its mission

          even  assuming timeliness, there is  no reason to suppose further

          indulgence  would bear fruit.   See Paterson-Leitch,  840 F.2d at
                                          ___ _______________

          991.

               2.  "Custodial Care" Exclusion
               2.  "Custodial Care" Exclusion
                    _________________________

                    The Plan defines "custodial care" as:

                    service designed to  help family members meet
                    the needs  of daily  living whether  they are
                    disabled or not[, including:] 

                         a.   walking or getting in  and out
                              of bed;

                         b.   personal  care   such  as  bathing,
                              dressing, eating  or preparing spe-
                              cial diets; or

                         c.   taking medication  which the family
                              member  would  normally be  able to
                              take without help.

          The evidence  presented before  the magistrate  judge established

          that the  nursing services provided by  Nightingale came squarely

                                          8

          within the  "custodial care"  exclusion:  preparation  of special

          diet,  feeding, performing  foot  massages,  "active and  passive

          Range of Motion exercises," and assisting the patient to and from

          the bathroom.  Thus, there was no error.1

          C.   Equitable Estoppel
          C.   Equitable Estoppel
               __________________

                    Nightingale contends that  Revere is equitably estopped

          from  denying  benefits  under  the  "custodial  care"  exclusion

          because these  nursing services  were provided to  Striesfield in

          reliance on  Revere's contrary  oral representations.   But since

          Nightingale has not demonstrated an ambiguity in the language  of
                                              _________

          the "custodial care" exclusion, the putative oral representations

          it attributes to  Revere were  offered to modify,  not merely  to
                                                             ___

          interpret, the ERISA Plan language.  Thus, its equitable estoppel

          claim cannot succeed.  Law v. Ernst & Young, 956 F.2d 364, 370-72
                                 ___    _____________

          (1st  Cir. 1992); Kane v. Aetna Life Ins., 893 F.2d 1283, 1285-86
                            ____    _______________

          (11th  Cir.), cert. denied, 498 U.S. 890 (1990).  See Schoonmaker
                        _____ ______                        ___ ___________

          v. Employee Sav. Plan of Amoco Corp., 987 F.2d 410, 412 (7th Cir.
             _________________________________

          1993)  (oral representations or  "other informal  statements" may

          not be used to contradict terms of ERISA plan); Greany v. Western
                                                          ______    _______

          Farm  Bureau Life  Ins. Co., 973  F.2d 812,  822 (9th  Cir. 1992)
          ___________________________

          (same); Coleman v. Nationwide Life Ins. Co., 969 F.2d 54, 59 (4th
                  _______    ________________________

          Cir. 1992) (same), cert. denied, 113 S. Ct. 1051 (1993); Degan v.
                             _____ ______                          _____

                            
        ____________________

             1Nor would  the untimely  Nightingale affidavit have  altered the
        "custodial  care" exclusion  ruling.   The  affidavit  does not  state
        whether the listed services were among  those previously reimbursed by
        Revere in the amount of $3,250,  nor does it reflect the dollar amount
        claimed  for  the services  purportedly  qualifying  as "private  duty
        nursing." 

                                          9

          Ford  Motor Co., 869  F.2d 889, 895  (5th Cir. 1989)  (same); see
          _______________                                               ___

          also Hozier v. Midwest  Fasteners, Inc., 908 F.2d 1155,  1164 (3d
          ____ ______    ________________________

          Cir.  1990) (ERISA  plan  not subject  to  amendment by  informal

          communication  between employer and  plan beneficiary);  Moore v.
                                                                   _____

          Metropolitan  Life Ins.  Co., 856  F.2d 488,  492 (2d  Cir. 1988)
          ____________________________

          (similar); Musto v. American  Gen. Corp., 861 F.2d 897,  910 (6th
                     _____    ____________________

          Cir. 1988) (clear terms  of written employee benefit plan  not to

          be modified  or  superseded by  "oral  undertakings" on  part  of

          employer), cert. denied, 490 U.S. 1020 (1989).  
                     _____ ______

          D.   Evidentiary Claims 
          D.   Evidentiary Claims
               __________________

                    Nightingale appeals various evidentiary rulings  by the

          magistrate judge.  We discuss only the challenged  rulings admit-

          ting in evidence the  essential documentary exhibits proffered by

          Revere, consisting of the Plan  document and the medical  records

          Nightingale submitted to Revere.

                    Nightingale contends  that the Plan document  itself is

          inadmissible  hearsay.   See  Fed. R.  Evid.  802.   We need  not
                                   ___

          address Revere's response that the Plan document comes within the

          "business  records exception"  to the hearsay  rule, see  Fed. R.
                                                               ___

          Evid. 803(6), since the Plan document itself is not hearsay.  See
                                                                        ___

          Kepner-Tregoe, Inc.  v. Leadership  Software, Inc., 12  F.3d 527,
          ___________________     __________________________

          540 (5th Cir.) ("Signed instruments such as wills, contracts, and

          promissory notes are writings that have independent legal signif-

          icance, and are nonhearsay.") (quoting Thomas A. Mauet, Fundamen-
                                                                  _________

          tals of Trial Techniques 180 (1988)), cert. denied, 115 S. Ct. 82
          ________________________              _____ ______

          (1994).   Rather, the Plan  constitutes a form  of verbal act  by

                                          10

          Revere and  Striesfield's employer.  Mueller v.  Abdnor, 972 F.2d
                                               _______     ______

          931, 937 (8th Cir. 1992); see also Kepner-Tregoe, 12 F.3d at 540;
                                    ___ ____ _____________

          2 John W. Strong et al., McCormick on Evidence   249, at 101 (4th
                                   _____________________

          ed. 1992).   The  Federal Rules  of Evidence explicitly  "exclude

          from  hearsay the entire  category of  `verbal acts'  and `verbal

          parts of an act,' in which the statement itself affects the legal

          rights of the  parties or  is a circumstance  bearing on  conduct

          affecting their rights."   Fed. R. Evid. 801(c)  advisory commit-

          tee's note.  

                    At  no time  has  Nightingale suggested  that the  Plan

          document admitted  in evidence  is not  the document  executed by
                                             ___

          Striesfield's  employer and  Revere.   Instead,  Nightingale  has

          focused on  the lack  of personal  knowledge on  the part of  the

          affiant  who attested that  a copy of  the Plan  document was at-

          tached  to the affidavit.  Insofar as this represented an attempt

          to assert that the  Plan document was not duly  authenticated, it

          fails to assert  a basis for questioning the  affiant's statement

          that the attached document is a copy of the Plan.  

                    Nightingale likewise objects to the Nightingale medical
                                                        ___________

          records  Revere introduced  to  support its  contention that  the

          nursing  services  provided  by  Nightingale  were  custodial  in
                                                              _________

          nature.  As  a practical matter, of  course, this is an  argument

          Nightingale cannot afford to win.   If Nightingale's own  nursing

          services records were inadmissible,  there would appear to be  no

          need  for Revere  to  justify its  disallowance of  Nightingale's

          claims  under  the Plan.   In  all  events, however,  the nursing

                                          11

          records Nightingale submitted to Revere constituted admissions of
                  ___________ _________

          a party opponent, not  hearsay, see Fed. R. Evid.  801(d)(2); see
                            ___           ___                           ___

          also  United States v.  Paulino, 13 F.3d  20, 24  (1st Cir. 1994)
          ____  _____________     _______

          (finding  money order  receipt an  adoptive admission  tending to

          prove appellant  financed apartment used  for drug  distribution,

          where  receipt  was  found  in  appellant's  possession,  bearing

          appellant's name and address, and labeled "May rent").  There was

          no  abuse of discretion in denying Nightingale's motion to strike

          the nursing records.  

                    Affirmed.
                    Affirmed.
                    ________

                                          12