Cook Children's Medical Center v. New England PPO Plan of General Consolidated Management, Inc.

491 F.3d 266, 2007 WL 1842117
CourtCourt of Appeals for the Fifth Circuit
DecidedJune 28, 2007
Docket06-10511
StatusPublished
Cited by26 cases

This text of 491 F.3d 266 (Cook Children's Medical Center v. New England PPO Plan of General Consolidated Management, Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fifth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Cook Children's Medical Center v. New England PPO Plan of General Consolidated Management, Inc., 491 F.3d 266, 2007 WL 1842117 (5th Cir. 2007).

Opinion

PRADO, Circuit Judge:

Cook Children’s Medical Center appeals the district court’s grant of summary judgment and award of mediation costs in favor of the defendants. For the reasons that follow, we AFFIRM the district court’s order granting summary judgment and VACATE the award of mediation fees as taxable costs under 28 U.S.C. § 1920.

I. BACKGROUND

A. Factual Background

David G. Miller (“Mr. Miller”) began his employment with Creative Education Inc., a company affiliated with General Consolidated Management, Inc. (“General Consolidated”), in September 2000. General Consolidated has a welfare benefit plan governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001-1461, which provides medical and other benefits to its employees and their beneficiaries.

On January 16, 2002, Mr. Miller asked General Consolidated to add his son, David C. Miller (“David”), as a covered dependent under General Consolidated’s ERISA plan, which at that time was insured through Aetna U.S. Healthcare. David was born on November 29, 2001, with congenital heart defects and other disabilities.

In early 2002, General Consolidated decided to no longer fund its ERISA plan through Aetna U.S. Healthcare. Effective April 1, 2002, General Consolidated replaced the Aetna Plan with a self-funded ERISA plan, under which New England Life Insurance Company (“New England”) provided excess coverage and administrative services for the plan. The open enrollment period for the new plan, the New England PPO Medical Plan of General Consolidated Management, Inc. (“Plan”), began on March 1, 2002, and ended on March 31, 2002.

*269 On March 2, 2002, Mr. Miller filled out a Benefit Plan Enrollment/Change Form for the Plan and listed David as one of his dependents to be enrolled in the Plan. On March 31, 2002, Mr. Miller removed David from his Plan enrollment form by crossing through David’s name and information. Underneath the line crossing through David’s name and information is a handwritten note on the enrollment form stating “[t]ake off per [Mr. Miller]. [David] is on Medicaid. 3-31-02. Phoned Irene.” In addition, Mr. Miller told Cathy Gunn of General Consolidated that David should not be enrolled in the Plan as one of his covered dependents. Mr. Miller took these actions during the open enrollment period and before the Plan’s effective date. Pursuant to Mr. Miller’s instructions, the Plan Administrator, Deborah Hansen (“Plan Administrator”), did not enroll David in the Plan.

Mr. Miller’s decision not to enroll David in the Plan was based on conversations he and his wife, Amy Miller (“Mrs. Miller”), had with Medicaid and Social Security Administration representatives. These representatives allegedly told the Millers that David’s medical care would be covered by Medicaid if Mr. Miller did not enroll David in the Plan.

David was covered by Medicaid in April 2002, and his Medicaid coverage continued until June 30, 2002. From April 9-22, 2002, David underwent medical treatment at Cook Children’s Medical Center (“Cook”). When David was admitted for treatment, the Millers informed Cook that David was covered by Medicaid. In addition, the Millers assigned to Cook any benefits to which David was entitled. 1

Cook filed its claim for David’s hospital bills with Medicaid. Medicaid paid Cook approximately $76,291.63 for David’s medical treatment in April 2002. 2

In June 2002, the Millers were notified that David’s Medicaid coverage would expire on June 30, 2002, because the Social Security Administration had determined that as of June 30, David would no longer qualify for supplemental security income. Because David’s Medicaid coverage was set to expire on June 30, Mr. Miller submitted a Benefit Plan Enrollment/Change Form on June 28, adding David to the Plan effective July 1, 2002. In a letter dated June 30, 2002, Mr. Miller stated:

I wish to add [David] to my policy ... effective 7/1/02. He was not enrolled during open enrollment because he was covered under Medicaid. I received a letter of denial from SSI Medicaid on June 11, 2002 stating he would no longer be eligible for coverage after 6/30/02.

The Plan enrolled David as of July 1, 2002.

After initially accepting payment from Medicaid for David’s April 2002 treatment, Cook later returned Medicaid’s $76,291.63 payment. 3 On December 31, 2002, Cook sent the Plan a demand letter, requesting that the Plan pay for David’s medical services from April 9-22, 2002, in the amount of $137,952.27.

*270 The Plan Administrator reviewed Cook’s request for payment. The Summary Plan Description (“SPD”) provides that

[t]he Plan Administrator has complete authority to control and manage the Plan. The Plan Administrator has full discretion to determine eligibility, to interpret the Plan and to determine whether a claim should be paid or denied, according to the provisions of the Plan as set forth in this booklet.

The Plan Administrator determined that David was not eligible for coverage for his treatment at Cook in April 2002 because Mr. Miller had not enrolled David in the Plan at that time. In making this determination, the Plan Administrator looked to language in the SPD, which provides that a plan participant “may elect not to be covered under this Plan for any benefits, or [ ] may waive coverage for all coverages except Life and AD&D Insurance, or [] may waive coverage for medical and prescription drug only.” Based on the administrative record, the Plan Administrator found that during the open enrollment period, Mr. Miller had removed David from his Benefit Plan Enrollment/Change Form by crossing through David’s name and by telling Cathy Gunn of General Consolidated to remove David from his enrollment form. The Plan Administrator noted that it was not until July 1, 2002, that Mr. Miller enrolled David in the Plan. Accordingly, because David was not enrolled in the Plan during his treatment at Cook, the Plan Administrator denied Cook’s request for payment.

B. Procedural History

On September 5, 2003, Cook filed this lawsuit against the Plan and the Plan Administrator. Cook alleged that David was a covered dependent under the Plan and that as David’s assignee, it was entitled to recover payment for David’s treatment in April 2002. The Plan and the Plan Administrator answered Cook’s complaint and filed a third-party complaint against New England for indemnification. The parties conducted discovery and attended mediation, 4 which was not successful.

The parties subsequently filed cross-motions for summary judgment. On September 14, 2005, the district court granted summary judgment in favor of the Plan, the Plan Administrator, and New England (collectively, “Defendants”), and denied Cook’s motion for summary judgment.

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491 F.3d 266, 2007 WL 1842117, Counsel Stack Legal Research, https://law.counselstack.com/opinion/cook-childrens-medical-center-v-new-england-ppo-plan-of-general-ca5-2007.