Judge sides with insurer in benefits lawsuit
No coverage for related services
Paul J. Dawson knew he faced a potentially lethal foe when he was diagnosed in the fall of 2005 with throat and neck cancer. But he said he soon encountered another formidable adversary: his union-sponsored health insurance plan.
Dawson, 60, a retired drywall finisher from Peabody, received intensive medical treatment that sent his stage 4 cancer into remission in early 2006, he said. His relief gave way to anger, however, when the Painters and Allied Trades District Council 35 Health and Welfare Funds refused to reimburse him $479.10 for repairs to three teeth that his dentist said had rotted because of radiation and chemotherapy.
Yesterday, in the same federal courthouse in Boston where Dawson's name is engraved among the hundreds of other tradespeople who helped construct the building, a federal judge sided with the insurance plan, even though she said the refusal to reimburse Dawson probably conflicts with "sound social and medical policy."
"Mr. Dawson's plan provides no catch-all category for medically necessary dental services, even though other plans may well cover such benefits and even though dental health and overall health are so clearly closely related," wrote US District Court Judge Nancy Gertner, who added that she had no choice but to dismiss the suit.
She pointed out that the union's insurance plan had gone so far as to transfer Dawson's lawsuit from small claims court in Peabody to federal court, where the filing fee is $350, and thus had almost certainly paid far more to defend the suit than it would have cost to reimburse Dawson.
The case, employment lawyers say, illustrates the limitations of the Employee Retirement Income Security Act, the 1974 federal law that protects employees' rights to their benefits.
The statute says administrators of health plans commit violations only if their actions are "arbitrary and capricious," a standard that lawyers say makes it hard for plaintiffs to mount successful challenges.
"The law is very weak and grants a huge amount of deference to plan administrators," said Robert Mantell, a lawyer in Boston and president of the Massachusetts Employment Lawyers Association.
Because of the "arbitrary and capricious" standard, he said, administrators of health plans are loath to make exceptions about benefits, because it could give other workers legal ammunition to follow suit.
"You would think that a company would want to save money on litigation fees and just pay the $500" Dawson sought, Mantel said. "But they would be setting a precedent to pay for other procedures."
Jonathan M. Conti, the lawyer who defended the union insurance plan and its administrator, Sharon Saganey, said it was unfortunate that Dawson cannot get reimbursed.
"But if the plan does not provide for those benefits, we can't authorize payment," he said.
Jonathan Saltzman can be reached at jsaltzman@globe.com.
