Devine v. American Benefit Corp.

27 F. Supp. 2d 669, 1998 WL 804967
CourtDistrict Court, S.D. West Virginia
DecidedNovember 13, 1998
DocketCiv.A. 2:97-1157
StatusPublished
Cited by2 cases

This text of 27 F. Supp. 2d 669 (Devine v. American Benefit Corp.) is published on Counsel Stack Legal Research, covering District Court, S.D. West Virginia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Devine v. American Benefit Corp., 27 F. Supp. 2d 669, 1998 WL 804967 (S.D.W. Va. 1998).

Opinion

MEMORANDUM OPINION AND ORDER

HADEN, Chief Judge.

Pending are (1) Defendant American Benefit Corporation’s (ABC) motion for summary judgment; (2) a motion for summary judgment filed by Defendant Counter-Claimants Association of Community Mental Health/Mental Retardation Programs of West Virginia Benefit Plan Trust (the Trust) and its Trustees; and (3) Plaintiff Nancy S. Devine’s counter motion for summary judgment against Defendants. The Court GRANTS Defendants’ motions for summary judgment and DENIES Devine’s motion. 1 This resolves the ease.

I. FACTUAL BACKGROUND

The Trust is an employee welfare benefit plan as defined in 29 U.S.C. section 1002(1). It provides health care benefits to covered employees and covered dependents of the participating employers in the Trust. The Trustees are designated by the Plan as its Administrator. They “have full and complete authority, responsibility, discretion and control over the Plant,]” including the authority (1) to “contract with certain organizations relative to monthly billing, claims payment and actuarial consultationf;]” and (2) to “do such other acts reasonably required to administer the Plan.” Ex. C, Def. ABC’s motion for summ. jgt. at 3.

To fulfill their duties, the Trustees contracted with ABC for the latter to provide monthly billing, claims payment and actuarial consultation services to the Trust. In sum, as a Third Party Administrator, ABC “pro-vid[es] all other necessary Claims Administration duties generally necessary to properly administer the Benefit Plan.” Ex. D. Def. ABC’s motion for summ. jgt. at 2.

The parties agree the 1994 version of the Plan is applicable here. The subrogation provision in the 1994 Plan provides, in part, as follows:

To the extent that benefits for covered services are provided or paid by the Plan, the Plan shall be subrogated and succeed to any and all rights of any Covered Employee or Covered Dependent for recovery of such paid expenses against any person, corporation, organization or other entity who may be liable for such expenses. Such Covered Employee or Covered Dependent shall be required by the Plan to provide information with respect to other persons, corporations, organization, or other entities which may be liable for expenses paid by the Plan. The Plan’s right of subrogation granted herein shall constitute a lien against any settlement or the proceeds of any judgement by a Covered Employee or Covered Dependent against a responsible third party.
Should a Covered Employee or Covered Dependent institute negotiations or a civil action to recover damages from a third party who may be liable for expenses paid by the Plan, the Covered Employee or Covered Dependent is required to notify his or her legal counsel of the Plan’s right of subrogation and subrogation lien.
Such Covered Employee or Covered Dependent may also be required to execute and deliver to the Plan a written confirmation and/or his or her legal counsel of the lien granted herein and certain other instruments that may be required to secure and protect the Plan’s right of subrogation. Failure to provide such information or documents, or failure to cooperate with the Plan in protection of its right of subrogation, may result in cancellation of benefits and/or denial of the claim upon which the Plan’s subrogation right is based, but such failure shall not affect the Plan’s right of subrogation.
The Covered Employee or Covered Dependent and/or his or her legal counsel shall pay the Plan all amounts recovered *672 by suit, settlement or otherwise from any third party to the extent of the benefits provided or paid under this Plan.

Ex. E., Def. ABC’s motion for summ. jgt. at 6.

Under the heading “GENERAL LIMITATIONS AND EXCLUSIONS!!,]” the Plan further provides:

No payment will be made under this Plan for expenses incurred in connection with:
40. Any illness or injury or other condition for which any person, corporation, organization or other entity may be liable or legally responsible by reason of negligence, an intentional act or breach of any legal obligation on the part of such person, corporation, organization or other entity provided such person, corporation, organization or other entity makes restitution for expenses incurred.

Id. at 19-20.

Devine was a Plan participant at all relevant times. Her son, John Devine, was likewise a covered dependent. Devine was provided a copy of the Summary Plan Description at the outset of her employment. She also acknowledged receiving subsequent updates to the SPD.

In June 1994, John Devine was assaulted by a third-party adult and required medical care. Devine submitted John’s medical bills to ABC for payment. ABC first learned of the attacker’s involvement in an August 1994 letter from Devine. Following Devine’s letter, ABC responded with a September 2, 1994 missive requesting her signature on a one-page subrogation agreement. Parenthetically, as is apparent from the subrogation provision, a writing is not required for the Plan to enforce its subrogation rights.

In an October 14, 1994 letter, Devine’s attorney informed ABC Devine would not sign the agreement. Counsel stated “While we recognize that under the insurance contract that you may have a contractual right of subrogation, we find that the language in your requested agreement form to be over-broad and inappropriate. Could you please send me a copy of the policy or plan.” Ex. J, Def. ABC’s motion for summ. jgt. (emphasis added).

On October 17, ABC sent to Devine a form letter virtually identical to that sent on September 2. On October 19 an ABC employee, Christa Martin, responded to counsel’s request for information. Martin forwarded only the subrogation provision. She stated, however, “Should you have any further questions regarding this matter, please do not hesitate to contact this office.” Ex. 2, PL’s reply.

On October 31, 1994 Devine’s attorney again refused to provide his client’s signature on the one-page subrogation agreement. Once again, counsel recognized the Plan’s contractual right of subrogation but argued the agreement was overbroad, citing two cases in support based upon state common law. Counsel included a proposed substitute subrogation agreement with his letter. On November 30, 1994 ABC sent a third form request for Devine to sign the subrogation agreement.

Because of Devine’s refusal to sign the subrogation agreement, ABC withheld payment of benefits to her. Subsequently, counsel for the Devines and counsel for the Trust, attorney R. Terrance Rodgers, had discussions in late 1994. Rodgers asserts it was agreed orally that if Devine protected the right of subrogation, ABC would be directed by the Trust to pay the withheld benefits. Devine denies any such agreement was reached and, for purposes of this motion, the Court accepts that, and any other disputed representation, as true. 2

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Related

Childers v. MedStar Health, Inc.
289 F. Supp. 2d 714 (D. Maryland, 2003)
Devine v. American Benefit Corp.
56 F. Supp. 2d 679 (S.D. West Virginia, 1999)

Cite This Page — Counsel Stack

Bluebook (online)
27 F. Supp. 2d 669, 1998 WL 804967, Counsel Stack Legal Research, https://law.counselstack.com/opinion/devine-v-american-benefit-corp-wvsd-1998.