Donna Cole Winters v. Costco Wholesale Corporation, a Washington Corporation Concept Administrators, Inc., a California Corporation

Costco Wholesale Group Benefits Program (the “Plan”) and Concept Administrators, Inc. (the “Plan Administrator”), appeal the district court’s summary judgment in favor of Donna Cole Winters in her action seeking reimbursement from the Plan for medical expenses related to a gamete intra-fallopian transfer (“GIFT”) procedure. The Plan is an employee welfare benefit plan subject to regulation under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 , et seq. We reverse and remand.

I.

FACTS AND PRIOR PROCEEDINGS

As a Costco employee, Winters was a participant in the company’s self-insured ERISA health benefits plan. Winters filed a timely claim for reimbursement of expenses related to a GIFT procedure performed on December 17, 1990. The procedure involves retrieving eggs from the patient’s ovaries and placing the eggs, along with sperm, in the patient’s fallopian tube.

Section 6.8 of the health plan excludes “[c]harges not reasonably necessary for the diagnosis and treatment of Illness or Injury.” Section 6.31 of the plan excludes from coverage “[e]harges in .connection with in-vitro fertilization.” There is no mention of GIFT procedures. Section 14.9…