Shirley Saltarelli, Individually & as the Adm'r of the Est. of Joseph Saltarelli v. The Bob Baker Grp. Med. Trust All-Am. Chevrolet-Geo Bob Baker Enter., Inc., Defendants-Cross-Claimants-Appellants v. Dave Hagen Factors, Inc., D/B/A Vip Chevrolet Downtown/future Ford Health Prot. Plan, Defendants-Cross-Defendants-Appellees, 35 F.3d 382 (9th Cir. 1994). · Go Syfert
Shirley Saltarelli, Individually & as the Adm'r of the Est. of Joseph Saltarelli v. The Bob Baker Grp. Med. Trust All-Am. Chevrolet-Geo Bob Baker Enter., Inc., Defendants-Cross-Claimants-Appellants v. Dave Hagen Factors, Inc., D/B/A Vip Chevrolet Downtown/future Ford Health Prot. Plan, Defendants-Cross-Defendants-Appellees, 35 F.3d 382 (9th Cir. 1994). Cases Citing This Book View Copy Cite
291 citation events (175 in the last 25 years) across 26 distinct courts.
Strongest positive: Fadi Haddad v. Smg Long Term Disability Plan (ca9, 2023-02-10)
Treatment trajectory · 1994 → 2026 · click a year to view as-of
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Top citers, strongest first. 50 distinct citers. How cited ↗
discussed Cited as authority (rule) Fadi Haddad v. Smg Long Term Disability Plan
9th Cir. · 2023 · confidence medium
Haddad argues that, under Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 385 (9th Cir. 1994), any limitations of or exclusions from coverage must be “clear, plain and conspicuous,” and that a reasonable layman should not have to hunt for exclusions or limitations in the policy.
cited Cited as authority (rule) McCulloch v. Hartford Life and Accident Insurance Company
N.D. Cal. · 2022 · confidence medium
Trust, 35 F.3d 382, 386-87 (9th Cir. 1994). 5 6 B.
cited Cited as authority (rule) Davis v. Einstein Noah Restaurant Group, Inc.
N.D. Cal. · 2022 · confidence medium
Trust, 35 F.3d 382, 386-87 (9th Cir. 1994). 5 6 B.
discussed Cited as authority (rule) McCluer v. Sun Life Assurance Company of Canada
S.D. Cal. · 2021 · confidence medium
Under this doctrine, a 26 27 28 1 ||conflicting summary of benefits or policy provided to an insured may become relevant 2 ||because, “[iJn general, courts will protect the reasonable expectations of applicants, 3 insureds, and intended beneficiaries regarding the coverage afforded by insurance carriers 4 || even though a careful examination of the policy provisions indicates that such expectations 5 |}are contrary to the expressed intention of the insurer.” Saltarelli v. Bob Baker Group 6 || Medical Trust, 35 F.3d 382, 386 (9th Cir. 1994) (quoting Robert E.
discussed Cited as authority (rule) Ruppert v. Atlas Air Inc
D. Alaska · 2019 · confidence medium
This is in keeping with ERISA itself which provides that a summary plan description “shall be written in a manner calculated to be understood by the average plan participant, and shall be sufficiently accurate and comprehensive to reasonably apprise such participants and beneficiaries of their rights and obligations under the plan.” 29 U.S.C. § 1022 (a). 23Id. at 32. -13- Plaintiff compares this case to Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 383 (9th Cir. 1994), which involved a pre-existing condition exclusion.
discussed Cited as authority (rule) Cynthia Stewart v. Snohomish County Pud No. 1
9th Cir. · 2018 · confidence medium
Whether an employer has breached its affirmative duty to accommodate—i.e., whether an accommodation is reasonable—is a question of fact, Phillips, 766 P.2d at 1103–04, entitled to deference, Saltarelli, 35 F.3d at 384.
discussed Cited as authority (rule) Howard Abrams v. Ins. Co. of No. America (2×) also: Cited "see"
9th Cir. · 2018 · confidence medium
Contrast Saltarelli, 35 F.3d at 385 (exclusion “bur[ied] . . . amidst definitions, rather than forthrightly stat[ed] . . . in the operative clauses of the plan description,” was not conspicuous).
examined Cited as authority (rule) Andre Lesgras v. Aetna Life Insurance (6×) also: Cited "see"
9th Cir. · 2015 · confidence medium
In so holding, we reasoned that “protecting the reasonable expectations .of insureds appropriately serves the federal policies underlying ERISA.” Id. at 386.
discussed Cited as authority (rule) King v. Blue Cross & Blue Shield of Illinois
S.D. Cal. · 2015 · confidence medium
The Doctrine of Reasonable Expectations Does Not Apply Plaintiff argues that the CRC’s interpretation is unreasonable is because it conflicts with his and Mrs. King’s “reasonable expectations,” relying on Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 387 (9th Cir.1994).
discussed Cited as authority (rule) Mull v. Motion Picture Industry Health Plan
C.D. Cal. · 2012 · confidence medium
We therefore held that the exclusion for pre-existing conditions “was not clear, plain, and conspicuous enough to negate layman Saltarelli’s objectively reasonable expectations of coverage.” Id. at 387.
cited Cited as authority (rule) Falcon Enterprises, Inc. v. Publishers Service, Inc.
9th Cir. · 2011 · confidence medium
Id. at 385.
discussed Cited as authority (rule) Sanchez v. TakeCare Insurance Company, Inc., a Guam Corporation (2×)
D. Guam · 2010 · confidence medium
Therefore, the Ninth Circuit “emphatically agree[d] with the district court finding that 21 the “purported exclusion for pre-existing conditions [was] not conspicuous enough to attract the 22 attention of a reasonable layman.” Id. at 385. 23 The reasonable expectation doctrine, which grew out of the law of adhesion contracts and 24 construction of ambiguities in insurance policies, has been described by the Ninth Circuit as 25 follows: 26 In general, courts will protect the reasonable expectations of applicants, insureds, 27 and intended beneficiaries regarding the coverage afforded by i…
discussed Cited as authority (rule) Scharff v. Raytheon Co. Short (2×)
9th Cir. · 2009 · confidence medium
In Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 387 (9th Cir. 1994), we “adopt[ed] the doctrine of reasonable expectations as a principle of the uniform federal common law informing 12818 SCHARFF v. RAYTHEON COMPANY interpretation of ERISA-governed insurance contracts.” At issue in Saltarelli was a pre-existing conditions exclusion that appeared in the SPD.
examined Cited as authority (rule) Scharff v. Raytheon Co. Short Term Disability Plan (4×)
9th Cir. · 2009 · confidence medium
In Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 387 (9th Cir. 1994), we "adopt[ed] the doctrine of reasonable expectations as a principle of the uniform federal common law informing interpretation of ERISA-governed insurance contracts." At issue in Saltarelli was a pre-existing conditions exclusion that appeared in the SPD.
cited Cited as authority (rule) Gillani Consulting Inc. v. Daewoo Heavy Industries America Corp.
9th Cir. · 2008 · confidence medium
Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 384 (9th Cir.1994).
discussed Cited as authority (rule) Kerber v. Qwest Group Life Insurance Plan
D. Colo. · 2008 · confidence medium
The doctrine is “a state law common law doctrine whereby courts will interpret policy language liberally to protect the reasonable expectations of insureds and intended beneficiaries, ‘even though a careful examination of the policy *1197 provisions indicates that such expectations are contrary to the expressed intention of the insurer.’ ” Pirkheim v. First Unum Life Ins., 229 F.3d 1008, 1011 (10th Cir. 2000) (citing Saltarelli, 35 F.3d at 386).
cited Cited as authority (rule) Shimko v. Guenther
9th Cir. · 2007 · confidence medium
Id. (citing Saltarelli, 35 F.3d at 385).
cited Cited as authority (rule) Shimko v. Guenther
9th Cir. · 2007 · confidence medium
Id. (citing Saltarelli, 35 F.3d at 385).
cited Cited as authority (rule) Perkins v. Prudential Insurance Co. of America
C.D. Cal. · 2006 · confidence medium
Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 388 (9th Cir.1994); Hummell v. S.E.
cited Cited as authority (rule) Abatie v. Alta Health & Life Insurance Company
9th Cir. · 2005 · confidence medium
Id. at 385. 50 The district court concluded that there was insufficient evidence to support Abatie's claim that a waiver of premium was ever requested or approved.
discussed Cited as authority (rule) Abatie v. Alta Health & Life Insurance (2×)
9th Cir. · 2005 · confidence medium
Id. at 385.
cited Cited as authority (rule) Shane v. Albertson's Inc. Employees' Disability Plan
C.D. Cal. · 2005 · confidence medium
Wheeler v. Dynamic Engineering, Inc., 62 F.3d 634, 638 (4th Cir.1995); Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 387 (9th Cir.1994). 1.
cited Cited as authority (rule) Banacky v. Prudential Insurance Co. of North America
9th Cir. · 2005 · confidence medium
Id. at 385.
discussed Cited as authority (rule) Gaines v. Sargent Fletcher, Inc. Group Life Insurance Plan (2×) also: Cited "see, e.g."
C.D. Cal. · 2004 · confidence medium
Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 386 (9th Cir.1994).
cited Cited as authority (rule) Mladen Zivkovic v. Southern California Edison Company
9th Cir. · 2002 · confidence medium
Id. at 385.
cited Cited as authority (rule) Hyung Joon Kim v. James W. Ziglar, Commissioner John Ashcroft, Attorney General
9th Cir. · 2002 · confidence medium
However, “we may affirm on any basis supported by the record.” Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 387 (9th Cir.1994).
cited Cited as authority (rule) Honolulu Joint Apprenticeship & Training Committee of United Ass'n Local Union No. 675 v. Foster
D. Haw. · 2001 · confidence medium
McElwaine, 176 F.3d at 1172 (citing Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 387 (9th Cir.1994)).
cited Cited as authority (rule) Puget Sound Energy, Inc. v. Utility Partners
9th Cir. · 2001 · confidence medium
Trust, 35 F.3d 382, 384-85 (9th Cir. 1994).
discussed Cited as authority (rule) Frank Pirkheim and Roxanne Pirkheim, as Parents of Logan Pirkheim v. First Unum Life Insurance, a Foreign Corporation (2×)
1st Cir. · 2000 · confidence medium
Under this modern doctrine, which derived from the law of adhesion contracts and construction of ambiguities in insurance policies, Saltarelli, 35 F.3d at 386, an insurer that wishes to avoid liability under an insurance contract “must not only use clear and unequivocal language evidencing its intent to do so, but it must also call such limiting conditions to the attention of the insured.” Leland v. Travelers Indem.
discussed Cited as authority (rule) Pirkheim v. First Unum Life (2×)
10th Cir. · 2000 · confidence medium
Under this modern doctrine, which derived from the law of adhesion contracts and construction of ambiguities in insurance policies, Saltarelli , 35 F.3d at 386, an insurer that wishes to avoid liability under an insurance contract “must not only use clear and unequivocal language evidencing its intent to do so, but it must also call such limiting conditions to the attention of the insured.” Leland v. Travelers Indem.
cited Cited as authority (rule) Provident Life & Acc. Ins. Co. v. Henry
C.D. Cal. · 2000 · confidence medium
Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 386-87 (9th Cir.1994); Cal-Farm Ins.
cited Cited as authority (rule) S.A. McElwaine an Unmarried Person, on Behalf of Herself and All Others Similarly Situated v. Us West, Inc., a Foreign Corporation
9th Cir. · 1999 · confidence medium
“Recovery of attorney’s fees does not necessarily depend upon the outcome.” Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 387 (9th Cir.1994).
discussed Cited as authority (rule) 22 Employee Benefits Cas. 1430, 98 Cal. Daily Op. Serv. 5375, 98 Daily Journal D.A.R. 7545, 98 Daily Journal D.A.R. 9892 Security Life Insurance Company of America, a Minnesota Corporation v. Garry L. Meyling, Defendant-Counter-Claimant-Appellant
9th Cir. · 1998 · confidence medium
In that regard, we have held that "ERISA preemption does not mean that general principles of state law are irrelevant to interpretation of ERISA-governed insurance contracts." Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 386 (9th Cir.1994).
discussed Cited as authority (rule) Security Life Insurance Co. of America v. Meyling
9th Cir. · 1998 · confidence medium
In that regard, we have held that “ERISA preemption does not mean that general principles of state law are irrelevant to interpretation of ERISA-governed insurance contracts.” Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 386 (9th Cir.1994).
cited Cited as authority (rule) Russian River Watershed Protection Committee Brenda Adelman v. City of Santa Rosa
9th Cir. · 1998 · confidence medium
Advocates v. City of Port land, 56 F.3d 979, 982 (9th Cir.1995), cert. denied, 518 U.S. 1018 , 116 S.Ct. 2550 , 135 L.Ed.2d 1069 (1996); Saltarelli 35 F.3d at 385.
discussed Cited as authority (rule) Jeanne Ellis v. Transamerica Occidental Life Insurance Company
9th Cir. · 1997 · confidence medium
The doctrine provides that: 7 [a]n insurer wishing to avoid liability on a policy purporting to give general or comprehensive coverage must make exclusionary clauses conspicuous, plain, and clear, placing them in such a fashion as to make obvious their relationship to other policy terms, and must bring such provisions to the attention of the insured. 8 Id., at 386. 9 The exclusionary language in question is adequately clear.
cited Cited as authority (rule) Lillie Green v. Hotel Employees & Restaurant Employees International Welfare-Pension Funds
9th Cir. · 1997 · confidence medium
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 110-11 (1989); Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 386 (9th Cir.1994).
cited Cited as authority (rule) Lincoln National Life Insurance v. Evans
D. Maryland · 1996 · confidence medium
See Wickman, 908 F.2d at 1084 ; Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 385-86 (9th Cir.1994); Southern Farm Bureau Life Ins.
examined Cited as authority (rule) Lancaster v. United States Shoe Corp. (7×) also: Cited "see"
N.D. Cal. · 1996 · confidence medium
The reasonable expectations doctrine examines “objectively reasonable expectations of coverage.” See Saltarelli 35 F.3d at 387 (emphasis added).
discussed Cited as authority (rule) 20 Employee Benefits Cas. 1375, 96 Cal. Daily Op. Serv. 4487, 96 Daily Journal D.A.R. 7305, Pens. Plan Guide P 23921c Gloria Snow v. Standard Insurance Company
9th Cir. · 1996 · signal: cf. · confidence medium
Cf. Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 386-87 (9th Cir.1994) (plan terms which exclude benefits despite reasonable expectation of coverage can be stricken) 2 That the application of those criteria was not an abuse of discretion can hardly be doubted.
discussed Cited as authority (rule) Snow v. Standard Insurance
9th Cir. · 1996 · confidence medium
Similarly, the doctrine of reasonable expectations cannot be used to strip the plan administrator of the discretion conferred on it based upon a circular theory that the very conferring of discretion cannot be anticipat ed. Cf. Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 386-87 (9th Cir.1994) (plan terms which exclude benefits despite reasonable expectation of coverage can be stricken). .
cited Cited as authority (rule) Steve L. Thomas v. California Department of Corrections
9th Cir. · 1996 · confidence medium
Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 384-85 (9th Cir.1994).
discussed Cited as authority (rule) McClure v. Life Insurance Co. of North America (2×) also: Cited "see"
9th Cir. · 1996 · confidence medium
Henry applied the principle of federal common law under ERISA that “courts will protect the reasonable expectations of ... insureds ... even though a careful examination of the policy provisions indicates that such expectations are contrary to the expressed intention of the insurer.” Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 386 (9th Cir.1994) (quotations omitted).
discussed Cited as authority (rule) 96 Cal. Daily Op. Serv. 3616, 96 Daily Journal D.A.R. 5936, Pens. Plan Guide (Cch) P 23925n Richard McClure v. Life Insurance Company of North America the Eg&g Voluntary Accident Insurance Plan Cigna Corporation Eg&g, Inc. (2×) also: Cited "see"
9th Cir. · 1996 · confidence medium
Soc'y, 894 P.2d 746, 755 (Colo.1995) ("proximate cause" in this context means "predominant cause"); 1A John A. Appleman & Jean Appleman, Insurance Law and Practice, § 362 at pp. 484-85, 490-91 (West 1981) (requirement that accident be "proximate cause" of disability not necessarily same as negligence standard; "The weight of authority is that such terms have no greater meaning that [sic] the usual rule requiring that the injury be a predominant factor in causing the loss."). 28 Henry applied the principle of federal common law under ERISA that "courts will protect the reasonable expectations …
discussed Cited as authority (rule) Fierro v. Gomez
9th Cir. · 1996 · confidence medium
Standard of Review. 32 Following a bench trial, the judge's "[f]indings of fact, whether based on oral or documentary evidence, shall not be set aside unless clearly erroneous." Fed.R.Civ.P. 52(a); Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 385 (9th Cir.1994).
discussed Cited as authority (rule) Fierro v. Gomez
9th Cir. · 1996 · confidence medium
Following a bench trial, the judge’s “[fjindings of fact, whether based on oral or documentary evidence, shall not be set aside unless clearly erroneous.” Fed.R.Civ.P. 52(a); Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 385 (9th Cir.1994).
discussed Cited as authority (rule) Vulcan Power Company, a Colorado Corporation v. Ce Exploration Company, a Delaware Corporation
9th Cir. · 1996 · confidence medium
STANDARD OF REVIEW 13 Following a bench trial, the court's findings of fact are reviewed for clear error, Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 384 (9th Cir.1994), and its conclusions of law are reviewed de novo.
discussed Cited as authority (rule) Granite State Insurance Company v. Smart Modular Technologies, Inc.
9th Cir. · 1996 · confidence medium
Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 384-85 (9th Cir.1994). “[R]eview under the ‘clearly erroneous standard’ is significantly deferential, requiring a ‘definite and firm conviction that a mistake has been committed.’ ” Concrete Pipe & Prods. v. Construction Laborers Pension Trust, 508 U.S. 602 , -, 113 S.Ct. 2264, 2280 , 124 L.Ed.2d 539 (1993).
cited Cited as authority (rule) Spokane Arcade, Inc. And World Wide Video of Washington, Inc. v. City of Spokane
9th Cir. · 1996 · confidence medium
See Price v. United States Navy, 39 F.3d 1011, 1021 (9th Cir.1994); Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 384 (9th Cir. 1994).
cited Cited as authority (rule) Buffets, Inc. v. Klinke
9th Cir. · 1996 · confidence medium
See Price v. United States Navy, 39 F.3d 1011, 1021 (9th Cir.1994); Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 384 (9th Cir.1994). 8 A grant of summary judgment is reviewed de novo.
Retrieving the full opinion text from the archive…
Shirley Saltarelli, Individually and as the Administrator of the Estate of Joseph Saltarelli
v.
The Bob Baker Group Medical Trust All-American Chevrolet-Geo Bob Baker Enterprises, Inc., Defendants-Cross-Claimants-Appellants v. Dave Hagen Factors, Inc., D/B/A Vip Chevrolet Downtown/future Ford Health Protection Plan, Defendants-Cross-Defendants-Appellees
Cited by 4 opinions  |  Published

35 F.3d 382

63 USLW 2244, 18 Employee Benefits Cas. 1982

Shirley SALTARELLI, individually and as the Administrator of
the Estate of Joseph Saltarelli, Plaintiff,
v.
The BOB BAKER GROUP MEDICAL TRUST; All-American
Chevrolet-Geo; Bob Baker Enterprises, Inc.,
Defendants-cross-claimants-Appellants,
v.
DAVE HAGEN FACTORS, INC., d/b/a VIP Chevrolet;
Downtown/Future Ford Health Protection Plan,
Defendants-cross-defendants-Appellees.

No. 92-56252.

United States Court of Appeals,
Ninth Circuit.

Argued and Submitted Feb. 1, 1994.
Decided Aug. 31, 1994.

Karl R. Lindegren, Fisher & Phillips, Newport Beach, CA, for defendants-cross-claimants-appellants.

Bruno Wolfenzon, Campell, Rubino, Torres & Wolfenzon, San Diego, CA, for defendants-cross-defendants-appellees.

Appeal from the United States District Court for the Southern District of California.

Before: D.W. NELSON, REINHARDT, and BRUNETTI, Circuit Judges.

BRUNETTI, Circuit Judge:

[*~382]1

Bob Baker Group Medical Trust appeals the district court's adverse finding of liability in a medical insurance dispute. We have jurisdiction pursuant to 28 U.S.C. Sec. 1291 and affirm.

I.

2

Downtown/Future Ford Health Protection Plan ("Future Ford") and Bob Baker Group Medical Trust ("Baker Group") are group health plans for two sets of affiliated auto dealerships. Joseph Saltarelli worked for a Future Ford dealership until January 5, 1990 and received medical coverage through the Future Ford plan. He then left Future Ford and began work at a Baker Group dealership on January 8, 1990. The Baker Group plan had a three-month waiting period before coverage began on April 8. Saltarelli passed a physical exam by Baker Group's chosen doctor on January 3, 1990.

3

For the interim, Saltarelli elected to continue his Future Ford coverage. Most group health plans are required to provide the opportunity to elect such continuation coverage under the terms of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. Secs. 1001 et seq. (1988), as amended by the Comprehensive Omnibus Budget Reconciliation Act of 1986 ("COBRA"), 29 U.S.C. Secs. 1161-68,[1] and Future Ford was no exception. Saltarelli continued his coverage by paying the full Future Ford premium for the months of January, February, and March. Near the end of March, Saltarelli received the Future Ford Plan's April bill. He paid it, but sent back the invoice with a handwritten notation: "Please send bill for Shirley [Saltarelli's wife] only May 1, 1990. I will be going off COBRA as of that date May 1, 1990." Future Ford accordingly billed Mrs. Saltarelli at the beginning of May, and she paid her premium.

4

On May 4, 1990, Saltarelli was hospitalized and in succeeding days was diagnosed with stomach cancer. Soon after the diagnosis, Baker Group advised that it would probably not cover his treatments because of the plan's pre-existing condition exclusion. On May 18, 1990, Saltarelli underwent surgery for the cancer. On May 23, 1990, the Saltarellis sent checks to Future Ford in payment of Joseph's May premium and their combined June premium. Mrs. Saltarelli enclosed a letter which stated: "Pursuant to 29 USC Section 1162(c), any payment made for COBRA coverage within 30 days after the date due is considered to be timely."[2]

5

On May 29, 1990, Joseph Saltarelli died. His widow subsequently demanded payment of his medical bills from both plans. Each plan denied any liability. Saltarelli's widow, as his executor, sued them both and they cross-claimed against each other. Baker Group later settled with Mrs. Saltarelli in exchange for an assignment of the estate's claims against Future Ford.

[*~383]6

Baker Group claims it is not liable because its coverage, for which Saltarelli became eligible in April 1990, excluded pre-existing conditions such as Saltarelli's subsequently diagnosed cancer. Future Ford claims it is not liable because, although Saltarelli maintained his old coverage through April 1990 under COBRA, he notified Future Ford before May that he would be "going off COBRA"; the plan argues that COBRA's 30-day grace period for premium payments did not apply to Saltarelli's May 23 attempt to pay up because he already had affirmatively terminated his coverage.

7

The case was submitted to the district court on the agreed facts for a bench trial to determine coverage liability. Adopting findings of fact and conclusions of law prepared by Future Ford, the district court found Future Ford not liable, holding that the Baker Group pre-existing condition exclusion was unenforceable and that Saltarelli's notice had irrevocably terminated his coverage under the Future Ford plan.

II.

A. Standard of Review

8

In reviewing a bench trial, this court shall not set aside the district court's findings of fact, whether based on oral or documentary evidence, unless they are clearly erroneous. Fed.R.Civ.P. 52(a). The clear error standard applies to those findings of fact the district court adopts from proposed findings submitted by the parties. See Anderson v. Bessemer, 470 U.S. 564, 571-73, 105 S.Ct. 1504, 1510-11, 84 L.Ed.2d 518 (1985); Barnett v. Sea Land Service, Inc., 875 F.2d 741, 745 (9th Cir.1989). Clear error review also applies to the results of "essentially factual" inquiries applying the law to the facts. See United States v. Martinez-Gonzalez, 962 F.2d 874, 878 (9th Cir.1992) (as amended). The district court's conclusions of law are reviewed de novo. Brooker v. Desert Hospital Corp., 947 F.2d 412, 415 (9th Cir.1991).

9

B. Baker Group's Pre-Existing Condition Exclusion

10

The Baker Group Summary Plan Description, which was provided to participants such as Saltarelli, covers 43 pages in single-spaced typescript. The preamble states that "[t]he Plan is subject to all terms, provisions and conditions recited on the following pages."

11

Among the Baker Group plan provisions is an exclusion for "pre-existing conditions." However, an insured reading the table of contents of the plan summary would find no heading for this critically important item. The only arguably relevant heading apparent from the table of contents, "Eligibility Rules: Employee Eligibility and Effective Date," contains no reference to it at all. The "Medical Care Benefits" chapter in the body of the document does reveal a subsection entitled "Exclusions and Limitations," but the pre-existing conditions exclusion receives no mention here either.

12

Instead, the exclusion can be found only in the midst of the "Definitions" chapter.[3] Even then, it requires a coordinated reading of three separate definitions: those for "Pre-Existing Condition," "Illness," and "Injury."[4] The district court found as matters of fact that:

[*~384]13

11. The Baker Group Plan's purported exclusion for pre-existing conditions is not conspicuous enough to attract the attention of a reasonable layman.

14

12. The Baker Group Plan's purported exclusion for pre-existing conditions is not clear or plain, inter alia, because it includes the term "illness", and [states that illness "must be medically diagnosed and receive treatment from a physician."] ...

15

16. As a reasonable layman, Mr. Saltarelli could not be expected to look under the medical definitions of The Baker Group Plan, for an exclusion for pre-existing conditions.

16

The court did not clearly err in making these findings; indeed, we emphatically agree with them. Baker Group chose to bury one of the plan's most significant provisions amidst definitions, rather than forthrightly stating the pre-existing conditions exclusion in the operative clauses of the plan description.

17

C. The Reasonable Expectations of the Insured

18

From these findings, the district court drew the legal conclusion that the Baker Group Plan exclusion was unenforceable. It cited no authority for this proposition.

19

Baker Group argues that Future Ford, the drafter of the court's conclusions, improperly imported state law authority here because ERISA preempts almost all state law which might otherwise bear upon interpretation of COBRA coverage. FMC Corp. v. Holliday, 498 U.S. 52, 56-58, 111 S.Ct. 403, 406-08, 112 L.Ed.2d 356 (1990); Kanne v. Connecticut General Life Ins. Co., 867 F.2d 489, 494 (9th Cir.1988), cert. denied, 492 U.S. 906, 109 S.Ct. 3216, 106 L.Ed.2d 566 (1989). Baker Plan correctly notes that Future Ford cited only California state law in arguing to the district court that the lack of a clear, plain, and conspicuous discussion of the exclusion rendered it unenforceable.

20

However, ERISA preemption does not mean that general principles of state law are irrelevant to interpretation of ERISA-governed insurance contracts. On the contrary, "[t]he courts are directed to formulate a nationally uniform federal common law to supplement the explicit provisions and general policies set out in ERISA, referring to and guided by principles of state law when appropriate, but governed by the federal policies at issue." Menhorn v. Firestone Tire & Rubber Co., 738 F.2d 1496, 1500 (9th Cir.1984); see also Evans v. Safeco Life Ins. Co., 916 F.2d 1437, 1439 (9th Cir.1990) ("interpretation of ERISA insurance policies is governed by a uniform federal common law"); Kunin v. Benefit Trust Life Ins. Co., 910 F.2d 534, 540 (9th Cir.) (state-law principle of contra proferentum applies to the federal courts' interpretation of ERISA insurance contracts), cert. denied, 498 U.S. 1013, 111 S.Ct. 581, 112 L.Ed.2d 587 (1990).

[*~385]21

In finding that the lack of a clear, plain and conspicuous statement of the exclusion rendered it unenforceable, the district court was applying the strong modern trend in insurance contract interpretation--the "reasonable expectations" doctrine. This doctrine, which grew out of the law of adhesion contracts and construction of ambiguities in insurance policies, has been formulated as follows:

22

In general, courts will protect the reasonable expectations of applicants, insureds, and intended beneficiaries regarding the coverage afforded by insurance carriers even though a careful examination of the policy provisions indicates that such expectations are contrary to the expressed intention of the insurer.

23

Robert E. Keeton & Alan I. Widiss, Insurance Law: A Guide to Fundamental Principles, Legal Doctrines, and Commercial Practices Sec. 6.3 (West 1988); see also Robert Keeton, Insurance Law Rights at Variance with Policy Provisions, 83 Harv.L.Rev. 961 (1970). For purposes of the instant case, the doctrine has been stated more specifically:

24

[a]n insurer wishing to avoid liability on a policy purporting to give general or comprehensive coverage must make exclusionary clauses conspicuous, plain, and clear, placing them in such a fashion as to make obvious their relationship to other policy terms, and must bring such provisions to the attention of the insured.

25

National Mutual Ins. Co. v. McMahon & Sons, Inc., 177 W.Va. 734, 356 S.E.2d 488, 496 (1987) (citation omitted); cf. Kunin, 910 F.2d at 540 (in the context of interpreting ambiguous provisions, "the insurer should be expected to set forth any limitations on its liability clearly enough for a common layperson to understand").

26

The application of the reasonable expectations doctrine to ERISA insurance contract interpretation presents a question of first impression in this circuit.[5] Two factors are significant in our consideration. First, protecting the reasonable expectations of insureds appropriately serves the federal policies underlying ERISA, including provision of adequate information to plan participants and protection of their interests.[6] Second, at least thirty states have explicitly incorporated some variation of the reasonable expectations doctrine into their own law, which demonstrates its widespread acceptance and vitality.[7]

27

We hereby adopt the doctrine of reasonable expectations as a principle of the uniform federal common law informing interpretation of ERISA-governed insurance contracts.[8] As a result, we affirm the district court's legal determination that, since Baker Group's attempted exclusion was not clear, plain, and conspicuous enough to negate layman Saltarelli's objectively reasonable expectations of coverage, it was unenforceable and Baker Group was liable for Saltarelli's medical expenses incurred beginning April 8, 1990.

D. Automatic Termination of COBRA Coverage

[*~386]28

In the second part of its analysis, the district court found that Saltarelli's note saying he would be "going off COBRA" had operated irrevocably to terminate his Future Ford coverage. We need not reach this issue, for the judgment that the Baker Group exclusion was unenforceable automatically terminates any liability for Future Ford and renders Baker Group solely liable.[9]

29

Although the district court did not so reason, in reviewing the decisions of the district court we may affirm on any basis supported by the record. United States v. Washington, 969 F.2d 752, 755 (9th Cir.1992), cert. denied sub nom. Lummi Indian Tribe v. Washington, --- U.S. ----, 113 S.Ct. 1945, 123 L.Ed.2d 651 (1993).

30

Section 1162(2)(D) of COBRA dictates that, absent other triggering events, plans need not make continuation coverage available after

31

The date on which the qualified beneficiary first becomes, after the date of the election--

32

(i) covered under any other group health plan (as an employee or otherwise) 'which does not contain any exclusion or limitation with respect to any pre-existing condition of such beneficiary' ...

33

29 U.S.C. Sec. 1162(2)(D). In other words, Congress recognized that continuation coverage may be a burden on group health plans and sought to minimize it by permitting quick termination when the insured obtains full protection from another plan.

34

Future Ford took advantage of this aspect of the law. The Future Ford plan summary description includes a table of contents heading called "Continuation of Coverage."[10] The text of that section clearly states: "Continuation of Coverage shall not be provided beyond whichever of the following dates is first to occur: ... 4. the date on which the Covered Person becomes covered under any other group health plan ..." Since the Baker Group plan exclusion was unenforceable, Sec. 1162(2)(D) and this provision operated to terminate Future Ford's potential liability on the day Saltarelli became covered by the Baker Group plan. We affirm the judgment of the district court.

III.

35

Both parties have requested attorney's fees on appeal pursuant to 29 U.S.C. Sec. 1132(g)(1). Recovery of attorney's fees does not necessarily depend upon the outcome. Oster v. Barco of Cal. Employees' Retirement Plan, 869 F.2d 1215, 1221 (9th Cir.1988). The factors relevant to the panel's determination include:

36

(1) the degree of the opposing parties' culpability or bad faith; (2) the ability of the opposing parties to satisfy an award of fees; (3) whether an award of fees against the opposing parties would deter others from acting under similar circumstances; (4) whether the parties requesting fees sought to benefit all participants and beneficiaries of an ERISA plan or to resolve a significant legal question regarding ERISA; and (5) the relative merits of the parties' positions.

[*~387]37

Id. at 1222 (quoting Hummell v. S.E. Rykoff & Co., 634 F.2d 446, 453 (9th Cir.1980)). None of these factors weighs for or against an award to either Baker Group or Future Ford. Both requests are denied.

AFFIRMED

1

These same provisions are also codified in the Internal Revenue Code, at 26 U.S.C. Sec. 4980B(f). For simplicity, all references here are to Title 29

2

Section 1162(2)(c) states in pertinent part: "The payment of any premium ... shall be considered to be timely if made within 30 days after the date due or within such longer period as applies to or under the plan."

3

An obscure reference to it does also appear in the "Late Enrollment Procedures and Conditions" subsection under "Eligibility Rules."

4

Section II.B., "Medical Definitions," begins on page 7 of the plan summary and reads as follows:

1

"Illness" shall mean bodily sickness or disease, psychiatric disorders, and congenital abnormalities of a newborn child. "Illness" must be medically diagnosed and receive treatment from a physician. For purposes of determining benefits payable, "illness" includes pregnancy

2

"Injury" shall mean accidental bodily injury sustained by the covered person while this Plan is in force on that covered person

5

"Pre-existing Condition" shall mean any injury or illness, which existed (with or without the affected person's knowledge) within nine (9) months before becoming eligible for coverage under this Plan. No medical, dental or disability benefits are payable under this Plan for pre-existing conditions or related conditions until coverage for the eligible person under this Plan has been in force for twelve (12) consecutive months

5

At least two other circuits have addressed the issue, if only obliquely. See Meester v. IASD Health Services Corp., 963 F.2d 194, 197 (8th Cir.1992) (where plan summary not ambiguous, "[t]here is therefore no occasion to apply the contra insurer or reasonable expectation doctrines", citing Delk, infra ) Delk v. Durham Life Ins. Co., 959 F.2d 104, 105-06 (8th Cir.1992) (per curiam) (distinguishing previous 8th Circuit case which held that ERISA preempts application of state-law doctrines of insurance contract interpretation and then applying contra insurer rule in an ERISA case); Pitts v. American Sec. Life Ins. Co., 931 F.2d 351, 355-56 (5th Cir.1991) (reasonable expectation of continued coverage supports holding that policy was voidable rather than void)

6

ERISA's statutory declaration of policy, 29 U.S.C. Sec. 1001 (1988), states that "owing to the lack of employee information and adequate safeguards concerning their operation, it is desirable in the interests of employees and their beneficiaries ... that disclosure be made and safeguards be provided with respect to the establishment, operation, and administration of such plans." 29 U.S.C. Sec. 1001(a). It continues:

It is hereby declared to be the policy of this chapter to protect ... the interests of participants in employee benefit plans and their beneficiaries, by requiring the disclosure and reporting to participants and beneficiaries of financial and other information with respect thereto, by establishing standards of conduct, responsibility, and obligation for fiduciaries of employee benefit plans, and by providing for appropriate remedies, sanctions, and ready access to the Federal courts.

29 U.S.C. Sec. 1001(b).

7

See Barry R. Ostrager & Thomas R. Newman, Handbook on Insurance Coverage Disputes Sec. 1.03[b] (6th ed. 1993) (citing cases)

8

We note, however, that "the reasonable expectation concept must be limited by something more than the fervent hope usually engendered by loss." Darner Motor Sales, Inc. v. Universal Underwriters Ins. Co., 140 Ariz. 383, 682 P.2d 388, 395 (1984) (en banc). We leave comprehensive delineation of the doctrine's scope to future cases

9

It also obviates the need to reach the matter, hotly debated in the parties' briefs, of the Baker Group plan administrator's interpretation of the scope of the exclusion. See Kunin, 910 F.2d at 540-41

10

Ironically, the Future Ford plan's table of contents also has a subheading entitled "Full Plan Medical Pre-Existing Conditions Limitation."