Court Rules Employee Benefit Plan Not Required To Pay For Home Health Care.(Brief Article)

Cecilia Wall, a resident of Lake Wylie, South Carolina, worked for the Homelite Division of Textron in Charlotte, North Carolina. In April 1994, she was diagnosed with an inoperable and terminal brain tumor which, a short time later, forced her to cease working. Her treating physician ordered home health care services beginning in July 1994. Even after Wall stopped working, Textron's medical benefits plan (the "Textron Plan") continued to provide Wall with benefits, compensating her for medical treatment, therapy, and even some custodial care.

Following Textron's sale of the Homelite Division to Deere & Company in August 1994, the Deere medical benefits plan (the "Deere Plan") succeeded the Textron Plan and provided similar coverage to the Homelite Division employees, effective January 1, 1995. Both plans were administered by The Prudential Insurance Company of America. Although Homelite Division workers became covered under the Deere Plan in January 1995, Wall was not provided with any information regarding the switch in coverage. To the contrary, when Wall's husband, Ernest Young, inquired of a Homelite Division representative in late summer 1994 about Wall's medical coverage, the representative told Young that because Cecilia was put on permanent disability before the sale to John Deere, her coverage would stay the same.

While still receiving benefits under the Textron Plan, Wall's doctor issued an order, effective December 18, 1994, instructing that Wall be given assistance of an unlicensed caregiver for "14 hours per day as requested by hospice/husband." The stated purposes of prescribing this caregiver were to help Wall with all activities of daily living; to prepare and serve meals to Wall as requested by Wall or her family; and to provide companionship for Wall, so as to allow her to die with dignity.

For the next two weeks, Wall was reimbursed expenses for this custodial care. Beginning January 3, 1995, however, when the Deere Plan succeeded the Textron Plan, the administrator refused to provide reimbursement for expenses of custodial care. This amount eventually totaled $ 8,859. The Deere Plan did, however, continue to pay Wall's medical expenses. In denying coverage for the custodial care, the administrator did not refer to any specific plan by name, and when Young requested a copy of the plan, ...