Harris v. Harvard Pilgrim Health Care, Inc.

20 F. Supp. 2d 143, 1998 U.S. Dist. LEXIS 14065, 1998 WL 568703
CourtDistrict Court, D. Massachusetts
DecidedAugust 7, 1998
DocketCivil Action 97-10259-PBS
StatusPublished
Cited by10 cases

This text of 20 F. Supp. 2d 143 (Harris v. Harvard Pilgrim Health Care, Inc.) is published on Counsel Stack Legal Research, covering District Court, D. Massachusetts primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Harris v. Harvard Pilgrim Health Care, Inc., 20 F. Supp. 2d 143, 1998 U.S. Dist. LEXIS 14065, 1998 WL 568703 (D. Mass. 1998).

Opinion

MEMORANDUM OF DECISION AND ORDER

SARIS, District Judge.

Defendant Harvard Pilgrim Health Care, Inc. (“HPHC”) seeks to enforce a hen against plaintiff Michael Harris for health care costs paid pursuant to the terms of HPHC’s Subscriber Agreement (“the Plan”), which is governed by the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. §§ 1001-1461. Harris received a lump-sum settlement from the party allegedly responsible for injuries he sustained in a motorcycle accident. HPHC alleges that it is entitled under both the Plan and Mass.G.L. c. Ill, §§ 70A-70D to recover out of the settlement the full cost of benefits provided. The Plaintiffs, Wendy and Michael Harris (“the Harrises”), brought suit against HPHC for violation of Mass.G.L. c. Ill, §§ 70A-70D (Count I), breach of contract (Count II), equitable subrogation (Count III), and unfair or deceptive trade practices (Count IV). HPHC counter-claimed for enforcement of its lien.

Moving for summary judgment, HPHC argues that the contract and unfair trade practice claims are preempted by ERISA and that it is entitled to the full amount for benefits provided with no reduction for attorney’s fees or risk of litigation. In their motion for summary judgment, the Harrises argue that Mass.G.L. c. Ill, §§ 70A-70D is preempted by ERISA and that HPHC’s lien should be reduced under the “make whole” doctrine. They also argue that HPHC should bear its pro rata share of the attorney’s fees incurred in obtaining the settlement. Although other courts have struggled with these arguments, they raise issues of first impression in this Circuit.

After hearing, the Court concludes that (1) the subrogation clause in the ERISA plan precludes the application of the “make whole” doctrine; (2) as a matter of federal common law, HPHC is required to pay its pro rata share of the reasonable attorney’s fees incurred in reaching a settlement with a third party tortfeasor; and (3) Mass.G.L. c. Ill, §§ 70A-70D and Mass.G.L. c. 93A are pre-empted.

*146 I. BACKGROUND

The Court treats the following facts as undisputed unless otherwise noted:

On August 23, 1991, Michael Harris was injured when he struck a roadway detour with his motorcycle. He received medical treatment for his injuries pursuant to the Plan administered by HPHC. 1 Harris was covered under the Plan through his wife’s employment at Somerville Hospital. HPHC provided $102,874.29 in health care costs between 1991 and 1993 for treatment of Harris’ injuries.

The Harrises filed suit in Massachusetts Superior Court against J .F. White Contracting Co., Inc. (“J.F.White”) and the Massachusetts Water Resources Authority, alleging that they were the parties legally responsible for Harris’ injuries. On May 13, 1996, after discovering the Harrises had filed suit, HPHC asserted a lien in the amount of $130,-384.80 upon the net amount payable by any third person to Harris as a result of the motorcycle accident. Later, on September 13, 1996, HPHC re-asserted the lien in the same amount.

The Harrises settled their negligence claim against J.F. White in August, 1996, in the amount of $737,500, of which $245,833.33 represented compensation to Harris’ counsel and $18,893.98 represented litigation expenses. The Harrises contend their settlement of the claims against the third parties was reasonable because of factual disputes as to whether Harris had been drinking at the time of the accident, and as to how fast Harris was reported to have been driving. The Harris-es’ counsel based his evaluation of the settlement on the litigation risks posed by these disputes and recommended accepting settlement which, in his opinion, represented at least a one-third discount of the value of fair compensation for the injuries. HPHC was not involved in the settlement negotiations, nor at any time did HPHC retain counsel to pursue claims against the third parties.

By letter to HPHC dated October 29,1996, the Harrises’ counsel informed HPHC that the Harrises’ claim against J.F. White had been settled. In the same letter, the Harris-es’ counsel asserted that the amount of HPHC’s lien was excessive on three grounds: (1) it included costs of treatment not arising from the accident; (2) it was not reduced to reflect costs expended to retain recovery, including attorney’s fees; and (3) it was not reduced to take into consideration the risks and uncertainties of litigation. The letter further asserted that HPHC’s lien calculation constituted an unfair or deceptive trade practice under Massachusetts law. On December 11, 1996, HPHC served a revised notice of lien in the amount of $102,874.29. The parties agree that the amount of the December 11, 1996 lien accurately reflects the cost of medical treatment provided by HPHC.

The Harrises then brought suit against HPHC in Massachusetts Superior Court on January 3, 1997, which HPHC removed. HPHC counter-claimed for enforcement of the lien and its recovery rights under the terms of the Plan, and now moves for summary judgment as to its claim and against each of the Harrises’ claims. The Harrises respond with a cross-motion for summary judgment on their lien determination claim.

II. DISCUSSION

The purpose of summary judgment is to “pierce the boilerplate of the pleadings and assay the parties’ proof in order to determine whether trial is actually required.” Wynne v. Tufts Univ. Sch. of Med., 976 F.2d 791, 794 (1st Cir.1992). A motion for summary judgment must be allowed if “the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law.” Fed.R.Civ.P. 56(c). “To succeed [in a motion for summary judgment], the moving party must show that there is an absence of evidence to support the nonmoving party’s position.” Rogers v. Fair, 902 F.2d 140, 143 (1st Cir.1990); see also Celotex Corp. v. Catrett, 477 U.S. 317, 325, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). “Once the moving party has properly supported its motion for summary judgment, the burden shifts to the ñoñ- *147 moving party, who 'may not rest on mere allegations or denials of his pleading, but must set forth specific facts showing there is a genuine issue for trial.’ ” Barbour v. Dynamics Research Corp., 63 F.3d 32, 37 (1st Cir.1995) (quoting Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986)). “There must be ‘sufficient evidence favoring the nonmoving party for a jury to return a verdict for that party.

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Bluebook (online)
20 F. Supp. 2d 143, 1998 U.S. Dist. LEXIS 14065, 1998 WL 568703, Counsel Stack Legal Research, https://law.counselstack.com/opinion/harris-v-harvard-pilgrim-health-care-inc-mad-1998.