Connecticut General Life Insurance Co. v. Grand Avenue Surgical Center, Ltd.

181 F. Supp. 3d 538, 61 Employee Benefits Cas. (BNA) 1097, 2015 WL 1868587, 2015 U.S. Dist. LEXIS 52811
CourtDistrict Court, N.D. Illinois
DecidedApril 21, 2015
DocketNo. 13 C 4331; No. 13 C 4994
StatusPublished
Cited by3 cases

This text of 181 F. Supp. 3d 538 (Connecticut General Life Insurance Co. v. Grand Avenue Surgical Center, Ltd.) is published on Counsel Stack Legal Research, covering District Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Connecticut General Life Insurance Co. v. Grand Avenue Surgical Center, Ltd., 181 F. Supp. 3d 538, 61 Employee Benefits Cas. (BNA) 1097, 2015 WL 1868587, 2015 U.S. Dist. LEXIS 52811 (N.D. Ill. 2015).

Opinion

MEMORANDUM OPINION AND ORDER

Elaine E. Bucklo, United States District Judge

Between June 2008 and December 2013, Grand Avenue Surgical Center (“GASC”) treated over one hundred patients who were members of a health insurance plan administered by Connecticut General Life Insurance Company (“CGLIC”), a subsidiary of Cigna Corporation.

In June 2013, CGLIC filed suit seeking a judgment declaring that GASC is not entitled to any reimbursement because the underlying health insurance plans exclude coverage where, as allegedly occurred here, a provider waives patient cost-sharing fees such as co-insurance, co-payments, and plan deductibles. GASC asserted a counterclaim seeking reimbursement of its charges at the percentage CGLIC allegedly promised to pay during telephone calls that GASC made before scheduling any surgical procedures.

The parties have filed cross motions for summary judgment on their competing claims. I dispose of the motions as follows for the reasons stated below: (1) CGLIC’s motion for summary judgment on GASC’s promissory estoppel claim is GRANTED only as to the “Schedule II” claims submitted between March 16, 2010 and August 15, 2012; (2) GASC’s cross motion for summary judgment on its promissory es-toppel claim is DENIED because there is a factual dispute about whether CGLIC made an unambiguous promise to pay; and (3) CGLIC’s declaratory judgment claim is DISMISSED as moot because GASC is not pursuing a denial of benefits claim under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq., as the assignee of its patients’ plan benefits.

I.

The following facts are undisputed unless noted otherwise. My presentation of the facts is divided into two sections: (1) a general description of GASC’s policies, practices, and procedures relating to patients with CGLIC-administered health insurance plans and (2) GASC’s history of submitting claims to CGLIC between June 2008 and December 2013.

A.

GASC operates an outpatient surgical center in downtown Chicago. Javad “Joe” Jafari has served as GASC’s administrator since the surgical center opened its doors in May 2008. Among other duties, Jafari is responsible for supervising the billing and collections specialists who work at GASC’s business office in Berwyn, Illinois.

When a surgeon wants to perform a procedure at GASC’s downtown office, he or she will submit a Surgery Request Form that includes a photocopy of the patient’s insurance card. GASC then at[541]*541tempts to verify that the patient’s insurance company will cover the planned procedure. At all relevant times, CGLIC played the following pre-recorded disclaimer at the beginning of all benefits verification calls:

The following information does not guarantee coverage or payment, The. governing document for a patient’s coverage is their Summary Plan Description. Payment for services will be based on medical necessity, plan provisions, and eligibility at the time of service.

Dkt. No. 112 (“GASC’s L.R. 56.1(b)(3)(B) Stmt.”) at ¶22.1 GASC admits that its employees heard this disclaimer when calling to verify insurance coverage. Id. at ¶ 25. As-an out-of-network provider, however, GASC did not have access to the plan documents referenced in CGLIC’s pre-re-corded disclaimer. Accordingly, GASC’s practice was to remain on the line long enough to speak with a live CGLIC agent who could verify the patient’s insurance information.

After identifying the patient and the billing code for the planned surgical procedure, GASC employees asked CGLIC’s customer service agents a series of questions set forth on a “Benefits Rundown Form,” including (1) the amount of any plan deductibles and how much of those amounts the patient had satisfied; (2) the percentage at which CGLIC would cover out-of-network services; and (3) the patient’s maximum out-of-pocket expense. Id. at ¶ 26(l)-(2). Jafari testified that GASC employees specifically asked—and CGLIC verified—the percentage of GASC’s billed charges that would be covered. See Dkt. No. 102-2 (“Jafari Dep:”) at 37, 76-77. 148, 156-57. In contrast, Erica Gallegos, a GASC employee who has made benefits verification calls from November 2008 to the present, testified that she did not ask CGLIC what percentage of GASC’s billed charges would be paid. See Dkt. No. 102-6 (“Gallegos Dep.”) at 51-52. According to Ms. Gallegos, she did not ask whether the percentage CGLIC quoted applied to GASC’s billed charges or some other amount because CGLIC would “never answer” that question. Id. at 41.

Setting aside this conflicting testimony for the moment, Jafari admits that GASC did not disclose to CGLIC an estimate of its billed charges when verifying insurance coverage and that CGLIC did not guarantee payment. Id. at 42-44, 172-73. GASC employees confirm that they did not discuss dollar amounts when calling CGLIC to verify coverage. GASC’s L.R. 56.1(b)(3)(B) Stmt, at ¶ 30(1). Indeed, CGLIC asserts that its customer service agents “are trained not to promise or guarantee payment to a provider during a pre-service call.” Dkt. No. 100-1 (“Cisar Declar.”)at ¶ 13.

After CGLIC verified the percentage at which it would cover GASC’s. billed charges, GASC scheduled the patient for surgery. On the day of the surgery, the patient assigned his or her health insurance benefits to GASC and executed a guaranty of payment. Jafari Dep. at 185-86. After the surgery, one of the employees in the Berwyn office prepared an insurance claim and presented it to Jáfari for review. Jafari, who rarely made changes to insurance claims, then instructed one of GASC’s employees to submit the [542]*542claim to the appropriate insurance company.

About thirty to sixty days later, GASC and the patient would receive an Explanation of Benefits (“EOB”) showing what percentage of the billed charges the insurance company was paying and any charges for which the patient was responsible. The EOBs that CGLIC sent to GASC are, in many cases, unclear about whether the patient owes cost-sharing fees. In June 2009, for example, CGLIC sent an EOB to GASC that listed deductible and co-insurance amounts of $500 and $2,000, respectively. See Dkt. No. 124-1 at 4. Yet the same EOB includes two statements that introduce confusion: (1) “the $500 out of network deductible has been satisfied for 2009” and (2) “the $2,500 out of network ‘out-of-pocket limit’ has been reached for 2009.” Id. According to CGLIC, GASC should have billed the patient for cost-sharing fees listed on the EOB in these circumstances; in other words, the language at the bottom of the EOB meant, “If the patient pays the cost-sharing fees shown above, then his or her plan deductible and out-of-pocket limit for 2009 will be satisfied.” GASC was not aware of this hidden meaning and interpreted such EOBs to mean that the patient had already satisfied all cost-sharing responsibilities. See Jafari Dep. at 197, 202.

After GASC received an EOB from CGLIC, one of GASC collections specialists prepared a patient bill for the cost-sharing fees shown on the EOB and presented the bill to Jafari for review. GASC’s L.R. 56.1(b)(3)(B) Stmt, at ¶37. Jafari testified that he rarely revised patient bills and denied that GASC ever waived patient cost-sharing fees based a surgeon’s or a patient’s complaint. Jafari Dep. at 180-81.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
181 F. Supp. 3d 538, 61 Employee Benefits Cas. (BNA) 1097, 2015 WL 1868587, 2015 U.S. Dist. LEXIS 52811, Counsel Stack Legal Research, https://law.counselstack.com/opinion/connecticut-general-life-insurance-co-v-grand-avenue-surgical-center-ilnd-2015.