Opinion
No. 1-807 / 01-298.
Filed February 20, 2002.
Appeal from the Iowa District Court for Floyd County, JOHN S. MACKEY, Judge.
Minor plaintiff injured in car accident and her father appeal from the district court order dismissing their breach of contract action against defendant health care insurer of minor plaintiff's step-father. AFFIRMED.
Roger L. Sutton of Sutton Law Office, Charles City, for appellant.
Patrick Michael McGraw of Brick, Gentry, Bowers, Swartz, Stoltze, Schuling Levis, P.C., Des Moines, for appellee.
Considered by VOGEL, P.J., and MILLER and EISENHAUER, JJ.
Minor plaintiff injured in car accident and her father appeal from the district court order dismissing their breach of contract action against defendant health care insurer of minor plaintiff's step-father. Plaintiffs contend the court erred by finding that the health care provider had no obligation to provide benefits. Plaintiffs also contend that they were not obligated under the plan to execute a subrogation agreement in favor of defendant following their settlement with other insurers. Finally, plaintiffs contend the court should have found defendant was estopped from denying coverage because it had made payments for plaintiff's medical expenses in the past without objection. We affirm.
I. Background Facts and Proceedings . On June 2, 1995, fifteen-year-old Robin McDonald was injured in a car accident while a passenger in a car driven by her friend, Lacey Griga. Robin incurred medical bills of $44,371.66. The tortfeasor, Joseph Kellogg, had liability insurance, and both Griga and Robin's father had policies with underinsured motorist coverage. Lacey, through her conservatorship, ultimately settled with each insurer for $25,000, $20,000, and $50,000 respectively.
Robin's parents, Robert and Carolyn, were divorced, and Robin was living with her mother and her stepfather, Donald Lokenvitz, at the time of the accident. Robert had an obligation under the dissolution decree to provide Robin with whatever medical insurance coverage was available to him through work. However, Robert was out of work at the time of the accident and had no coverage. Instead, Donald submitted a claim for Robin's medical expenses through his employee benefit health care plan. The plan is governed by the federal Employee Retirement Income Security Act (ERISA), both by statutory definition 29 U.S.C. § 1002(a)(a) and by designation. The plan provider, Extended Benefits, Inc., denied coverage. Robert and Robin filed a breach of contract action. Cambrex Corporation administered the plan and was brought into the suit by Extended Benefits as a third-party defendant. Following a bench trial, the district court dismissed the suit. Robin appeals.
II. Breach of Contract . Plaintiffs contend the court erred by finding Donald's health care plan did not provide coverage for Robin. They also contend the court erred by finding Robin was obligated to execute a subrogation agreement on behalf of the plan provider as a condition precedent to receiving coverage. In the alternative they argue Extended Benefits should be estopped from denying coverage because they provided some benefits for her in the past. Our review is for errors at law. Iowa R. App. P. 4.
Donald's health insurance plan states that only eligible dependents may be enrolled for coverage under the plan. The plan defines a dependent as a stepchild "who is principally dependent upon the Employee for support and for whom the Employee had legal responsibility to support." Citing the testimony of Robert McDonald and Donald Lokenvitz, who both admitted Donald had no legal responsibility to support or provide medical insurance for Robin, the court held Robin was not an eligible stepchild of Donald. However, under Iowa law, a step-father is legally obligated to support his step-child. Fransen v. Iowa Dept. of Human Services, 376 N.W.2d 903, 907 (Iowa 1985). Both parties on appeal focus on and argue whether Donald was legally obligated to support Robin. The appellants cite the fact that the mother asked Donald to include Robin on his insurance, and that some claims had been paid for Robin. The appellees cite the testimony of the parents and the step-father. Neither side cites the Fransen case. The record is devoid of evidence concerning whether Robin was "principally dependent" on Donald for support. The decree of dissolution of marriage requires Robert to pay child support and nothing was offered to suggest he didn't pay it. The defendants in their answer raise the issue of whether the plaintiffs met the requirements of the plan. Thus, plaintiffs had the burden to prove eligibility. They offered no evidence that Robin was principally dependent on Donald for support.
Although, we find the district court was in error in finding Donald had no legal responsibility to support or provide medical insurance for Robin, we must affirm as there is no evidence Robin was principally dependent on Donald.
In the alternative, Plaintiffs assert that Extended Benefits has waived its arguments, or should be estopped from denying coverage, because of having made prior medical care payments for Robin's benefit without objection. They also suggest Robin is entitled to coverage under the doctrine of reasonable expectations. The plan states: "Any waiver of the Plan Administrator or Plan supervisor to enforce a provision of this Plan shall not effect any right thereafter to enforce such provision or any other provisions of this Plan."
Claims for benefits are governed by the plain language of the plan. See Davolt v. Executive Committee, 206 F.3d 806, 810 (8th Cir. 2000). Because both of Plaintiffs' claims are defeated by the plain language of the plan, we affirm the decision of the district court, denying Plaintiffs' breach of contract claim. We need not consider their claims on appeal relating to subrogation.
AFFIRMED.