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Walsh v. Empire Blue Cross/Blue Shield Inc.

Union's Benefits Plan Did Not Cover Experimental, Investigational Botox Injections

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MEMORANDUM & ORDER  Plaintiff Mary Ellen Walsh (“Plaintiff” or “Walsh”) commenced this action against defendant Empire Healthchoice Assurance, Inc. (“EHA”), Empire Health Choice HMO (“HMO”) and Empire Blue Cross/ Blue Shield (“BC/BS”) (collectively “Defendants”) under section 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974 (“ERISA”) to recover benefits she contends are due her under the terms of an employee welfare benefit plan. Presently before the Court is Plaintiff’s motion and Defendants’ cross-motion for summary judgment. For the reasons set forth below, Plaintiff’s motion is denied and Defendant’s motion is granted.BACKGROUNDThe following facts are undisputed unless otherwise noted.1I. The PartiesPlaintiff is a beneficiary of the Plumbers Local Union No. 1 Welfare Fund (the “Welfare Fund”) an employee welfare benefit plan within the meaning of section 3(1) of ERISA. On February 24, 2016 when the services at issue were provided, she was eligible for benefits in accordance with the terms of the self-insured plan of benefits (the “Plan”) sponsored by the Welfare Fund. EHA performs claims adjudication services and makes its network of hospitals, doctors and other medical providers available to the Welfare Fund’s participants and beneficiaries in accordance with an administrative services agreement with the Welfare Fund. EHA does not act as an insurer with respect to the Welfare Fund or its Plan. When EHA approves a claim for payment, the Welfare Fund pays the claim and thus EHA has no financial stake in how claims are adjudicated. (Defs.’ 56.1 Statement

3-6.) HMO has no relationship to Plaintiff or with the Welfare Fund and that BC/BS is not a legal entity but rather a name under which EHA and HMO conduct business. (Langhorne Aff. (DE 27-4)

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