United States District Court, D. Colorado
NELSON VETANZE, doing business as OMNI CHIROPRACTIC, Plaintiff,
NFL PLAYER INSURANCE PLAN, Defendant
For Nelson Vetanze, doing business as, Omni Chiropractic, Plaintiff: Keith Evan Frankl, Frankl Law Firm, P.C., The, Denver, CO.
For NFL Player Insurance Plan, Defendant: Jack M. Englert, Jr., Steven T. Collis, Holland & Hart, LLP-Greenwood Village, Greenwood Village, CO.
R. Brooke Jackson, United States District Judge.
This is an appeal from the denial of benefits under an ERISA plan. The case
has featured an unusual degree of quarreling about the administrative record and the standard of review. Ultimately, however, it was briefed on the merits and became ripe for review by this Court on March 22, 2013. The matter thereafter tumbled through the cracks, and for that the Court extends its apology to the parties and counsel. For the reasons set forth in this order, the denial of benefits is reversed, and the case is remanded for further proceedings consistent with this order.
The NFL Player Insurance Plan provides medical benefits for eligible NFL players and their dependents. NFL 1. It is self-funded by contributions from each NFL club on a per-capita basis to the NFL Players Insurance Trust. NFL 163, 165-66, 218, 221. The Plan does not cover " charges for an injury resulting from your employment or occupation" or for " an illness that is covered by Workers' Compensation or similar law." NFL 189, 244.
The Plan grants the Trustees " full discretionary authority to interpret the Plan and to resolve all questions that arise under the Plan, including questions of fact." NFL 211, 266. The Plan also designated CIGNA as a third-party administrator to administer the determination and payment of claims for medical benefits. Specifically, the Trustees " have delegated the discretionary authority to apply the terms of the Plan and to make factual determinations to . . . CIGNA in connection with all claims for Self Funded Benefits." Id. CIGNA has no financial responsibility for the payment of benefits. Id.
During a meeting of the Trustees on June 3, 2010 a representative of the NFL Management Council expressed a concern that the Plan appeared to be paying numerous claims for chiropractic services that were work-related and therefore not covered by the Plan. NFL 274. She suggested that the Trustees adopt a presumption that chiropractic services received by an active player in training camp or on or near a game date are work-related. NFL 275. Under this proposal, which the Trustees unanimously adopted, " a player who submitted a claim for chiropractic services provided within these periods would need to establish to CIGNA's satisfaction that the services were provided for a sickness or injury that is not work-related in order for the Plan to pay it." Id.
In a memo from the NFL Management Council dated July 10, 2010 the NFL Clubs were informed that the Plan was changing its coverage for chiropractic claims filed " during the 2010 playing season." NFL 61. The memo stated, among other things, that " the Plan will not pay claims filed for chiropractic services performed during each Club's Training Camp.," and that the changes would be reflected in the Plan and its Summary Plan Description. Id. The memo added that, although the Summary Plan Description would be provided upon publication, the memo was being sent to provide advance notice since the changes " will be in effect soon." Id.
By letter dated August 2, 2010 the Plan informed CIGNA that " [n]o chiropractic claims should be paid for chiropractic services performed during each Club's Training Camp, which is the period from the opening of camp through the Club's final pre-season game." NFL 62. The letter attached a list of the 2010 training camp dates for each club, none of which had yet begun. NFL 63.
The Denver Broncos' camp opened on July 28, 2010 and closed with the team's final pre-season game on September 2, 2010. NFL 63. During the Broncos' 2010 training camp 21 players received chiropractic treatments from Dr. Vetanze. Dr. Vetanze in turn submitted claims to CIGNA on pre-printed claim forms. See, e.g., Ayers 1. In the Ayers example the form indicates that the treatment was provided on July 30, 2010; the diagnosis is indicated by code numbers, 739 1, 739 2, 739 3 and 739 6; a check in a box indicates that the injuries were not related to Mr. Ayers' employment; and it is not indicated that he missed work. Id. It appears that Dr. Vetanze might be indicating that he provided treatment for the same or similar injuries on October 17, 2009, but if so, the date is placed in the wrong box. Id.
Exhibit 1 to Dr. Vetanze's Opening Brief provides information apparently obtained by counsel from the Internet that indicates that the four code numbers on the Ayers claim are for nonallopathic lesions of the cervical region, thoracic region, lumbar region and lower extremities. [#53-1 at 2]. The same codes in addition to codes for treatment of nonallopathic lesions of the pelvic region and upper extremities, headaches, unspecified fractures, foot dislocations and sprains of the cruciate ligament of the knee appear to cover most or all of the treatments rendered to players during the 2010 training camp. The record also contains treatment notes. E.g., Ayers 5-6. These notes mean little to me, but possibly to a professional in the field they might add something of significance to the question whether ...