Chief U.S. District Judge Fernando J. Gaitan, Jr. of the U.S. District Court for the Western District of Missouri declared that the denial of benefits to plaintiff John Benckeser was reasonable in light of the plan’s requirement that nondisabled children over 18 must be “devoted principally to attending school or college as a full-time student.”
According to Gaitan’s ruling, Benckeser is the stepson of Mark Rogers, a covered participant under the Carpenters’ District Council of Kansas City and Vicinity Health Plan. From February 21, 2002 until May 13, 2002, Benckeser underwent medical treatments, including chiropractic services, arthroscopic surgery and physical therapy for an injury to his left shoulder. These treatments totaled approximately $16,000.
The court said Benckeser was 22 years old and
attending school at Longview Community College at the time
he underwent medical treatment. The plan denied his
medical claims during the spring semester because he was
not a full-time student, interpreting the eligibility
provision to require a student to take at least 12 hours.
Benckeser was taking 11 hours.
After first determining the plan decisionmaker had discretionary authority to interpret the plan, Gaitan upheld the benefit denial based on ineligibility during the spring semester, noting that the college’s catalog defined a “full load” as being at least 12 credit hours during the fall and spring semesters.
“While another reasonable interpretation of the Plan existed, surely the Appeals Committee’s interpretation is not unreasonable when congressional statutes require 12 credit hours and 12 credit hours is a common requirement for students to acquire full-time status at most colleges and universities including plaintiff’s institution,” Gaitan wrote.
The case is John Benckeser versus Carpenter’s District Council of Kansas City, Missouri, No. 05-0657-CV-W-FJG, W.D. MO.