Bay Area Roofers Health & Welfare Trust v. Sun Life Assurance Co. of Canada

73 F. Supp. 3d 1154, 2014 U.S. Dist. LEXIS 158048, 2014 WL 5795042
CourtDistrict Court, N.D. California
DecidedNovember 6, 2014
DocketCase No. 13-cv-04192-BLF
StatusPublished
Cited by1 cases

This text of 73 F. Supp. 3d 1154 (Bay Area Roofers Health & Welfare Trust v. Sun Life Assurance Co. of Canada) is published on Counsel Stack Legal Research, covering District Court, N.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bay Area Roofers Health & Welfare Trust v. Sun Life Assurance Co. of Canada, 73 F. Supp. 3d 1154, 2014 U.S. Dist. LEXIS 158048, 2014 WL 5795042 (N.D. Cal. 2014).

Opinion

ORDER

(1) GRANTING IN PART AND DENYING IN PART DEFENDANT’S MOTION FOR SUMMARY JUDGMENT

(2) GRANTING PLAINTIFFS’ MOTION FOR PARTIAL SUMMARY JUDGMENT

BETH LABSON FREEMAN, United States District Judge

This ease involves interpretation of provisions of a stop-loss insurance policy issued by Defendant Sun Life Assurance Company of Canada (“Sun Life”) regarding the scope of its contractual obligation to reimburse Plaintiff Bay Area Roofers Health and Welfare Trust (“the Trust”) for claims paid on behalf of a worker’s minor children for medical care. Sun Life asserts that coverage is precluded because [1157]*1157the worker obtained his employment by fraud through submission of a false Social Security Number (“SSN”). The Trust asserts that it determined that the worker was an eligible employee under the Health and Welfare Plan and thus, as required by the Policy, Sun Life is contractually obligated to reimburse it for its claims. Cross-motions for summary judgment are presently before the Court.

Plaintiffs are a Trust created for the purpose of providing health care benefits for employees and their dependents in the roofing industry, and two of its Trustees. The Trust purchased a stop-loss insurance policy (“the Policy”) from Sun Life in order to mitigate costs related to large health care expenses that would otherwise fall upon the Trust’s self-funded Health and Welfare Plan (“the Plan”). In 2011, the third-party administrator of the Plan submitted reimbursement claims to Sun Life under the Policy for medical expenses paid out by the Plan for newborn twin dependents of a Plan participant, Participant X.1 The twins were born prematurely and accrued substantial medical expenses for their treatment.

Defendant Sun Life is an insurance company that offers, among other plans and policies, stop-loss insurance policies that provide reimbursement to self-funded employee benefit plans for covered medical expenses incurred by employees. Upon receipt of Plaintiffs’ claims and its own investigation, Sun Life denied the Trust’s claims based on its determination that Participant X was not a covered “employee” for purposes of the Policy coverage because Participant X lacked a valid Social Security Number. Sun Life claims that the absence of a valid SSN means that Participant X obtained his employment by fraud and was not authorized to work in the United States, thus precluding him from being an “employee” for purposes of insurance coverage under the Policy. Following Sun Life’s denial of Plaintiffs’ claims, and two unsuccessful internal appeals of that denial, Plaintiffs brought suit.

After reviewing the parties’ papers, evidence, and oral argument, as well as the governing law, the Court GRANTS IN PART AND DENIES IN PART Defendant’s Motion for Summary Judgment, and GRANTS Plaintiffs’ Motion for Partial Summary Judgment.

I. BACKGROUND

A. Procedural History

Plaintiffs filed their Complaint on September 10, 2013, alleging four causes of action, including breach of contract, breach of the. covenant of good faith and fair dealing, and violations of California Business and Professions Code §§ 17200 et seq. and the Employee Retirement Income Security Act (“ERISA”) § 502(a)(3)(B)(ii). Defendant answered on October 18, 2013, and after Plaintiffs filed a successful Motion to Strike, filed an Amended Answer on January 6, 2014.

On April 17, 2014, this case was reassigned to the undersigned. On April 25, 2014, the parties filed their cross-motions for summary judgment. Following briefing, the Court heard oral argument on August 7, 2014.

B. Undisputed Facts

The Trust is a multiemployer Taft>-Hart-ley Trust, created to provide employee benefits, including healthcare benefits and life insurance, for employees and their dependents covered by collective bargaining agreements in the roofing industry in the Bay Area. See Callahan Decl. ¶¶ 1, 3; see also id. Exh. A at 21 (Article I of the [1158]*1158Trust Agreement). The Plan, which is self-funded, id. at ¶ 5, is administered by a Joint Board which includes equal representation from labor and management, and which has the exclusive authority to manage the operations of the Trust and its assets. Id. Exh. A at 22, 38-41.

The Joint Board, in order to mitigate the effects of large health claims due to the self-funded nature of the Plan, purchased the Policy from Sun Life in August 2009, and renewed the Policy on August 1, 2010 and August 1, 2011. See Callahan Decl. ¶ 6. Upon renewal in 2010, and thereafter, the Policy’s deductible was $150,000. Id. at ¶ 7, Exh. B p. 24. The Trust provided Defendant with data regarding its past health insurance claim history, and also provided Defendant with a de-identified census, which included, among other information, the age,' zip code, and number of dependents of each Plan participant. Barrett Decl. ¶ 5. Every month, to continue receiving coverage under the Policy, the Trust provided a head count of total Plan participants. Id. at ¶ .6. The Trust is not the employer of any of its covered employees.

The Policy includes two provisions regarding the obligations of the insurer to make a reimbursement to the Plan:

This is a reimbursement policy. You, or your Plan administrator, are responsible for making benefit determinations under Your Plan. We have no duty or authority to administer, settle, adjust, or provide advice regarding claims filed under Your Plan.
We have the right to require documentation from You that demonstrates You paid an Eligible Expense and that payment was made in accordance with the terms of your Plan.... For the purpose of determining Eligible Expenses under this Policy, We have the right to determine whether an expense was Paid by You in accordance with the terms of Your Plan.

Rollinson Aff., Exh. B. at 1,18.

In May 2011, Participant X, a Plan participant, timely enrolled his newborn twins in the Plan. Barrett Decl. ¶ 7. The twins, who are citizens of the United States, were born prematurely, and incurred substantial medical expenses, with the Trust paying over $250,000 for Twin A’s medical treatment and over $450,000 for Twin B’s medical treatment. Id.

In November 2011, the Plan’s third-party administrator, ’ United Administrative Services (“UAS”), submitted claims to Sun Life seeking reimbursement for the medical expenses greater than the $150,000 deductible per dependent. Barrett Decl. ¶ 8, Exh. B at 1-4. Later, in August 2012, UAS submitted a subsequent reimbursement claim for additional expenses paid out by the Plan for additional treatment for Twin B. In total, the Plan sought reimbursement from Sun Life in the amount of $408,841.59. Id. ¶¶ 7-8; Exh. B. at 3-6.

The Plan’s claim forms, submitted to Sun Life, included Participant X’s name and a Social Security Number, which ended in “0724.” Rollinson Aff. ¶ 7, Exhs. D, E. Following receipt of the claim forms, Sun Life requested additional information from Plaintiffs, including Participant X’s original Plan enrollment form, see Barrett Decl. ¶ 11; on his enrollment form, Participant X included the same SSN ending in “0724,” Rollinson Aff. ¶ 9, Exh. F.

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Bluebook (online)
73 F. Supp. 3d 1154, 2014 U.S. Dist. LEXIS 158048, 2014 WL 5795042, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bay-area-roofers-health-welfare-trust-v-sun-life-assurance-co-of-canada-cand-2014.