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University of Wisconsin Hospitals and Clinics Authority v. Bank of America Group Benefits Program

United States District Court, W.D. Wisconsin

May 10, 2016

UNIVERSITY OF WISCONSIN HOSPITALS AND CLINICS AUTHORITY, Plaintiff,
v.
BANK OF AMERICA GROUP BENEFITS PROGRAM, Defendant.

OPINION AND ORDER

BARBARA B. CRABB, District Judge

Plaintiff University of Wisconsin Hospitals and Clinics Authority contends that defendant Bank of America Group Benefits Program improperly denied plaintiff benefits under the terms of the Bank of America Benefits Program, an employee benefit plan subject to the Employee Retirement Income Security Act. In an effort to recover these benefits, plaintiff has filed a claim under 29 U.S.C. § 1132(a)(1)(B). Both parties have filed motions for summary judgment on plaintiff’s ERISA claim.

After reviewing the parties’ briefs and supporting materials, I am granting defendant’s motion and denying plaintiff’s. Although plaintiff is empowered to sue under § 1132(a)(1)(B) as the assignee of a plan beneficiary, the plan beneficiary who assigned her claim to plaintiff never submitted a claim for benefits under the plan, did not exhaust her administrative remedies and is not entitled under the plan to the benefits plaintiff is seeking. By obtaining an assignment of its patient’s claims under the plan, plaintiff is entitled to raise a claim under § 1132(a)(1)(B), but it is not relieved of any of the prerequisites or limitations on claims generally applicable to the plan’s beneficiaries. In other words, plaintiff may have acceded to its patient’s rights under the benefit plan, but those rights do not entitle the patient to payment for the services plaintiff provided. Instead, plaintiff’s right to payment, if any, is governed by its in-network provider agreement with Aetna.

From the parties’ summary judgment materials and the record, I find that the following facts are material and not subject to genuine dispute.

UNDISPUTED FACTS

Defendant Bank of America Group Benefits Program is an employee benefits plan governed by the Employee Retirement Income Security Act. The plan, which is offered to Bank of America employees, includes a group health insurance policy offered and administered by Aetna. J.F. is a former Bank of America employee and a plan participant entitled to health insurance coverage under the Aetna group health insurance policy.

In November 2009, J.F. was given a diagnosis of chronic renal disease and underwent a renal transplant. In early-2014, J.F. began to experience symptoms suggesting that her pancreas was rejecting the renal transplant. She was admitted to the University of Wisconsin Hospital twice in March 2014: first on March 7, 2014 and then again on March 18, 2014. Over the course of these two stays, J.F. underwent various tests and received treatments. The cost for these services was approximately $150, 000.

J.F.’s hospital stays were covered by the Aetna policy associated with her benefit plan, which provides that Aetna will pay 80% of the covered cost. Moreover, because plaintiff is an “in-network” provider, J.F. was not required either to precertify her hospital stays or submit claims to Aetna for reimbursement. These requirements-precertification and claims submission-were plaintiff’s responsibility. The plan informs its insured participants that although precertification is required for certain services, when they are treated by a network provider, the precertification request “must be submitted by [the] provider.” Similarly, with respect to insurance claims, participants are informed: “You have no claim forms to file for services provided by an in-network provider. The physician and/or facility will file these claims with Aetna for you.” (It appears that the provider’s precertification obligations and claim submission requirements are described in a separate “provider contract” between Aetna and plaintiff. Although the parties refer to this agreement at various places in the record, neither party has submitted it in connection with its motion.)

Although it was plaintiff’s responsibility, plaintiff did not precertify either of J.F.’s hospital stays before admitting her for treatment. In both cases, plaintiff requested precertification one day after plaintiff was admitted-March 8 for the first stay and March 19 for the second. In both instances, Aetna denied plaintiff’s late precertification requests. Notwithstanding Aetna’s refusal to grant plaintiff’s precertification requests, plaintiff continued to provide J.F. inpatient treatment services and then attempted to charge Aetna for the services. Aetna refused to pay plaintiff for the treatment it provided J.F. during her two hospital stays because plaintiff “fail[ed] to follow [the] contractual notification requirements.” Aetna also informed plaintiff that J.F. was not responsible for the charges. (Neither party presents any evidence that plaintiff has billed J.F. for her treatment and neither party explains why she has not been billed.)

On June 18, 2014, plaintiff attempted to appeal Aetna’s decision to deny payment for the services plaintiff provided to J.F.. In both appeals letters, plaintiff stated: “With regard to late notification, our office attempted online notification through Navinet on [the day following plaintiff’s admissions] within our contract guidelines.” Aetna denied plaintiff’s appeals for payment in two letters dated June 26 and 27, which related to the second and first admission respectively. In both letters, Aetna explained that payment was properly denied “due to failure to follow Aetna contractual notification requirements” and that plaintiff could further appeal its decision in writing. The letter informed plaintiff that “[a] complete description of [plaintiff’s] appeal rights and submission timeframes can be found on [Aetna’s] secure provider website via Navinet[.]”

On November 5, 2014-131 days after plaintiff’s initial appeal was denied-counsel for plaintiff sent Aetna a letter, which he referred to as a “second level appeal.” Counsel stated in the letter that although Aetna denied payment “due to alleged untimely notifications, ” plaintiff had attempted to notify Aetna “within 24 hours of admission through Navinet, which [was] within [plaintiff’s] contractual guidelines with Aetna.” (Again, the “contractual guidelines” referred to in counsel’s letter are not before the court.) On December 23, Aetna denied plaintiff’s second level appeal on the ground that it was untimely. Aetna explained that “appeal requests must be filed within 60 days of the reconsideration decision. Because we reconsidered your claim on appeal on 06-27-2014, and we did not receive this appeal request until 11-10-2014, our previous decision regarding these charges will remain unchanged.”

Two days after Aetna denied plaintiff’s second level appeal, J.F. executed an assignment granting plaintiff all rights to insurance payments or other benefits to which she is entitled under the plan. Plaintiff made one last effort to secure payment on January 9, 2015 and when that request was denied, filed suit against Aetna in the Circuit Court for Dane County on March 27, 2015, asserting a variety of state law claims. After the case was removed to this court, plaintiff dismissed its claims against Aetna pursuant to Fed.R.Civ.P. 41 and filed an amended complaint against defendant Bank of America Group Benefits Program seeking benefits under 28 U.S.C. § 1132(a)(1)(B).

OPINION

Plaintiff is proceeding on a claim for benefits under 28 U.S.C. § 1132(a)(1)(B), which provides that an employee benefit plan “participant or beneficiary” may bring a civil action to “recover benefits due to him under the terms of his plan, enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” Defendant contends that plaintiff’s claim under § 1132(a)(1)(B) fails for three reasons. First, plaintiff is not entitled to file suit under § 1132(a)(1)(B) because it is neither a “participant [n]or beneficiary” under the Employee Retirement Income Security Act. Second, even if plaintiff did qualify as a participant or beneficiary, plaintiff did not exhaust the ...


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