2 No. 69
Edward J. Harvey, Jr., &c.,
Respondent,
v.
Members Employees Trust for Retail Outlets,
Appellant.
_________________________________________________________________
2001 NY Int. 44
April 26, 2001
This opinion is uncorrected and subject to revision before publication
in the New York Reports.
Richard M. Howard, for appellant.
Mark E. Goidell, for respondent.
_________________________________________________________________
LEVINE, J.:
Edward J. Harvey, Sr., a shareholder of a retail liquor store,
purchased medical reimbursement health coverage from defendant Members
Employees Trust for Retail Outlets (METRO), a self-insured health
benefit plan. METRO was established by the Metropolitan Package Store
Association, a trade association of liquor stores, to provide health
benefits to the employees of participating association members.
Harvey's store was a member of the association and participated in the
METRO plan.
Harvey's medical records indicate that he suffered from various
illnesses caused by alcohol abuse, including cirrhosis of the liver.
He was hospitalized twice in 1994 and ultimately died in the hospital
from hypovolemic shock and liver failure. The METRO plan denied
coverage for Harvey's hospitalization and medical care on the ground
that it did not provide benefits for illnesses arising from the use of
alcohol. Thereafter, plaintiff, as the executor of Harvey's estate,
brought this action for a judgment declaring that METRO was obligated
to reimburse the estate for Harvey's hospital and medical bills.
Plaintiff moved, and METRO cross-moved, for summary judgment.
Supreme Court denied plaintiff's motion, granted METRO's cross motion
and dismissed the complaint. The Appellate Division reversed, granted
summary judgment to plaintiff and remitted the matter to Supreme Court
for entry of a judgment declaring that METRO was obligated to
reimburse Harvey's estate for the medical and hospital bills (272 2
SNIPPETS:
Mark E. Goidell, for respondent.
Edward J. Harvey, Sr., a shareholder of a retail liquor store, purchased medical
METRO was established by the Metropolitan Package Store Association, a trade association of
Harvey's medical records indicate that he suffered from various illnesses caused by alcohol
He was hospitalized twice in 1994 and ultimately died in the hospital from hypovolemic shock
The METRO plan denied coverage for Harvey's hospitalization and medical care on the ground
granted summary judgment to plaintiff and remitted the matter to Supreme Court for entry of a
The court held that Insurance Law § 3221 and its implementing regulations did not permit an
The court also determined that Insurance Law § 3221 and its implementing regulations were not
The first issue before us on this appeal is whether the Insurance Law and its implementing
Conceding that the Insurance Law and regulations apply to health benefit self-insurers, METRO
Before its amendment in 1999, Insurance Law § 3221 expressly provided that "very insurer
on provides that "o policy shall limit or exclude coverage by type of illness, accident, treatment
It then interprets the regulation as allowing the exclusion of coverage for illnesses arising
In this way, the statute promotes the legislative goal "to promote and expand * * * health
Rather, it "controls the administration of benefit plans" by imposing, among other things,
ERISA provides an extensive and complex pre-emption scheme to facilitate the maintenance of a
The application of the Insurance Savings Clause to preserve State insurance regulation is in
The determination that ERISA's general pre-emption provision is triggered in this case does
Plaintiff urges, however, that the Deemer Clause is inapplicable to the METRO plan because,
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