Cahill v. Eastern Benefit Systems, Inc.

603 N.E.2d 788, 236 Ill. App. 3d 517, 177 Ill. Dec. 718, 1992 Ill. App. LEXIS 1689
CourtAppellate Court of Illinois
DecidedOctober 19, 1992
Docket1-91-1460
StatusPublished
Cited by34 cases

This text of 603 N.E.2d 788 (Cahill v. Eastern Benefit Systems, Inc.) is published on Counsel Stack Legal Research, covering Appellate Court of Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Cahill v. Eastern Benefit Systems, Inc., 603 N.E.2d 788, 236 Ill. App. 3d 517, 177 Ill. Dec. 718, 1992 Ill. App. LEXIS 1689 (Ill. Ct. App. 1992).

Opinion

JUSTICE O’CONNOR

delivered the opinion of the court:

This appeal questions the propriety of an order of the circuit court dismissing plaintiff Kevin Cahill’s fourth amended complaint, which sought damages from defendants, Eastern Benefit Systems and Care America, for failure to pay all of an insurance claim submitted by Ca-hill.

We affirm.

Cahill’s complaint, as amended, alleged that he was employed by Wieboldt Stores, Inc., 1 and, as a result of his employment, was provided with health insurance for both himself and his family. The insurance claim at issue here concerns the November 11, 1986, admission of Cahill’s son, Stephen, to Palos Community Hospital by his physician, Dr. Voltolina, and his subsequent 36-day stay at the hospital. The hospital ultimately submitted a bill for $13,615.40 to Wieboldt’s for Stephen’s stay. Wieboldt’s, in turn, paid $4,720.05 of the bill, claiming that Stephen’s hospitalization should have only been 14 days as opposed to 36 days.

Cahill further alleged that Eastern was the agent of Wieboldt’s for “the purpose of approving, administering and paying all medical and hospitalization claims submitted by insureds of [Wieboldt’s]” and that Care America was the agent of both Eastern and Wieboldt’s for the “purpose of investigating and making recommendations regarding medical and hospitalization claims submitted to both Eastern and Wieboldt’s.” Cahill stated that the contract between Wieboldt’s, Eastern, and Care America was for the direct benefit of Cahill and his family, that is, to provide insurance coverage and payment of medical and hospitalization costs to Cahill and his family.

In count I of the complaint, Cahill charged defendants with breach of Cahill’s insurance contract because only a portion of the hospital bill was paid. Count II alleged a violation of section 155 of the Illinois Insurance Code (Ill. Rev. Stat. 1989, ch. 73, par. 767.) In count III, Cahill charged that Care America had a duty to review the submitted insurance claims with reasonable care and that Care America breached that duty with regard to its determination that Stephen should have been hospitalized for only 14 days. Cahill further charged that Eastern negligently relied upon Care America’s wrong determination, thereby breaching its duty to administer the submitted insurance claims with care.

Attached to the complaint was a document entitled “Special Benefit Addendum.” This document states that the employee benefits plan “includes a Medical Utilization Review Program involving the services of Care America, an independent medical review organization. The Intent of the program is to eliminate inappropriate medical services while at the same time helping to contain the costs of your medical care.” The document contained instructions that the insured must follow in order to receive “maximum benefits in the event you or a family member may require surgery or hospitalization.” One such requirement was that the insured notify Care America before any hospital admission. The document also identified a “non compliance penalty” which warned that “the fact that a physician or another provider has furnished, ordered or approved a service or supply does not, of itself, make the service medically necessary.” The failure of an insured to contact Care America would “result in a fifty percent (50%) reduction of benefits otherwise payable for covered expenses which are medically necessary.”

Both Eastern and Care America moved to dismiss the complaint, arguing that Cahill had failed to state a cause of action upon which relief could be granted. In a written decision, the circuit court ruled that Cahill failed to allege facts which showed that Care America and Eastern had a contractual duty owing to Cahill. The court also found that the Insurance Code was inapplicable to the facts presented in the complaint. Finally, the court held that Cahill had failed to allege any facts which would create any duty in tort owing to Cahill. As a result, the complaint was dismissed.

Generally, courts are to construe pleadings liberally, with the view to do substantial justice between the parties. (Keller v. State Farm Insurance Co. (1989), 180 Ill. App. 3d 539, 536 N.E.2d 194.) No pleading, therefore, is defective in substance if it contains facts which reasonably inform the opposite party of the nature of the charge to be answered. (Keller, 180 Ill. App. 3d at 546.) A motion to dismiss based upon section 2 — 615 of the Code of Civil Procedure (Ill. Rev. Stat. 1989, ch. 110, par. 2 — 615), however, challenges the sufficiency of the complaint and should be decided solely upon the allegations the complaint sets forth. (Perkins v. Collette (1989), 179 Ill. App. 3d 852, 534 N.E.2d 1312.) The motion is to be granted only if it is clear that plaintiff cannot prove any set of facts under the pleading which would entitle him to the relief requested. Perkins, 179 Ill. App. 3d at 856.

Cahill contends that his complaint adequately alleged facts which prove that he was a third-party beneficiary to the contracts between Wieboldt’s and Care America and Eastern. We disagree.

In Illinois, an individual not a party to a contract may only enforce the contract’s rights when that contract’s original parties intentionally enter into the contract for the direct benefit of the individual. (Carson Pirie Scott & Co. v. Parrett (1931), 346 Ill. 252, 178 N.E. 498; Wheeling Trust & Savings Bank v. Tremco Inc. (1987), 153 Ill. App. 3d 136, 505 N.E.2d 1045.) Courts must determine whether the benefit to the third person is direct to him or is but an incidental benefit to him arising from the contract. (Carson Pirie Scott & Co., 346 Ill. at 257, Wheeling Trust & Savings Bank, 153 Ill. App. 3d at 140.) The critical inquiry centers on the intention of the parties, which is to be gleaned from the language of the contract and the circumstances surrounding the parties at the time of its execution. (People ex rel. Resnik v. Curtis & Davis, Architects & Planners, Inc. (1980), 78 Ill. 2d 381, 400 N.E.2d 918.) The promisor’s intention must be shown by an express provision in the contract identifying the third-party beneficiary. People ex rel. Resnik v. Curtis & Davis, Architects & Planners, Inc., 78 Ill. 2d at 385.

Here, the only contractual obligation which can be evinced from the complaint is that between Wieboldt’s and Cahill. Cahill failed to attach to his complaint any contract between Wieboldt’s and Care America and Eastern; therefore, we are unable to ascertain the intention of the parties with regard to Cahill. The attached “Special Benefit Addendum” does not satisfy the requirement for the original contract. Parenthetically, we note that it appears from the record that Cahill failed to follow the hospital preadmission instructions, which conceivably explains the reduction in the benefits received by Cahill.

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Cite This Page — Counsel Stack

Bluebook (online)
603 N.E.2d 788, 236 Ill. App. 3d 517, 177 Ill. Dec. 718, 1992 Ill. App. LEXIS 1689, Counsel Stack Legal Research, https://law.counselstack.com/opinion/cahill-v-eastern-benefit-systems-inc-illappct-1992.