DEATH DURING VOLLEYBALL COMPENSABLE, COURT SAYS

A worker's estate was entitled to workers compensation benefits for his death while playing volleyball during a break, according to the Supreme Court of New Hampshire.

James Balamotis, a field service engineer employed by Digital Equipment Corp., played volleyball with his co-workers several times per week during his lunch hour break. Volleyball was not a company-sponsored recreational activity; however, it was not forbidden. In June 1992, Mr. Balamotis died during a lunchtime game at the company, probably the result of an aggravated heart condition. His estate filed for workers comp benefits.

The compensation board denied benefits because his death did not arise out of and in the course of his work.

On appeal, the appellate court said accidents sustained during personal activities at work arise as much out of the employment as when actually doing the work. In general, the court held that on-premises recreational activities conducted during the work day arise out of employment.

Further, the court said the accident here occurred during the course of work because the activity was reasonably acceptable so as to be an incident of employment and, thus, in essence a part of it. The board's decision was reversed.

Appeal of Estate of Balamotis, Supreme Court of New Hampshire, Nov. 21, 1996, Rehearing denied Dec. 20, 1996 (BI/03/Jy.- $10).

ERISA can't be used to recover benefits

An employer, who was a fiduciary with respect to a health care plan, could not bring suit under the Employee Retirement Income Security Act to recover benefits for an employee, the 4th U.S. Circuit Court of Appeals ruled.

Until 1991, Coyne & Delany Co. maintained a group health insurance plan under contract with Blue Cross & Blue Shield of Virginia. The policy was cancelled and replaced with a self-insured plan reinsured by Standard Security Life Insurance Co. The reinsurance policy paid any benefit obligations incurred by Coyne in excess of $10,000. The new plan was effective April 1, 1991.

Prior to that date, Herman Tyree, a Coyne employee, had been hospitalized for a heart condition. He was on sick leave on April 1 and did not return to work before being readmitted to the hospital on April 20 for the same condition. Mr. Tyree's family was assured by Coyne that he was covered under the self-insured plan. Coyne paid $160,000 to Mr. Tyree's health providers and sought reimbursement from Standard. However, Mr. Tyree was not covered because he had failed to meet the "active service" requirement of the reinsurance plan. Thus, Coyne sued Blue Cross claiming the latter violated its fiduciary duties under ERISA by unreasonably denying Mr. Tyree benefits. The trial court denied Coyne any monetary recovery but ordered Blue Cross to pay Mr. Tyree's medical services claims.

The appellate court noted that Coyne was seeking medical benefits which it claimed are owed to Mr. Tyree. But, the court said that ERISA permits only "a participant or beneficiary" to sue for benefits.

The court said that the text, structure and purpose of ERISA all lead to one conclusion-that Coyne could not bring a suit to recover benefits for Mr. Tyree. "Any change in the stature will have to come from Congress," the court said, "not the courts."

The trial court decision was reversed.

Coyne & Delany v. Blue Cross & Blue Shield of Va., 4th U.S. Circuit Court of Appeals, Dec. 16, 1996 (BI/02/Jy.-$10)

These abstracts were prepared by Mayo H. Stiegler. Copies of these decisions are available by sending a $10 check payable to Mayo H. Stiegler, to Business Insurance, 740 N. Rush St., Chicago, Ill. 60611-2590. List the number for each opinion.