ISMIE Mutual Insurance v. Michaelis Jackson & Associates, LLC

921 N.E.2d 1156, 397 Ill. App. 3d 964, 337 Ill. Dec. 18, 2009 Ill. App. LEXIS 1332
CourtAppellate Court of Illinois
DecidedDecember 30, 2009
Docket5-08-0426
StatusPublished
Cited by16 cases

This text of 921 N.E.2d 1156 (ISMIE Mutual Insurance v. Michaelis Jackson & Associates, LLC) 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
ISMIE Mutual Insurance v. Michaelis Jackson & Associates, LLC, 921 N.E.2d 1156, 397 Ill. App. 3d 964, 337 Ill. Dec. 18, 2009 Ill. App. LEXIS 1332 (Ill. Ct. App. 2009).

Opinion

JUSTICE CHAPMAN

delivered the opinion of the court:

In this declaratory judgment action, defendants Michaelis Jackson & Associates, LLC, and Michaelis Billy Jackson, M.D. (collectively Jackson), appeal from the trial court’s July 16, 2008, order granting the motions filed by ISMIE Mutual Insurance Company (ISMIE) for a judgment on the pleadings and for a summary judgment from the trial court’s order of the same date denying Jackson’s motion for a summary judgment. At issue was ISMIE’s duty to defend and indemnify Jackson for a suit brought by Marsha Turner and Carolyn Swartos, former employees of Jackson. These former employees had filed a qui tam suit against Jackson and alleged that Jackson had performed numerous medically unnecessary cataract surgeries and invasive follow-up procedures. ISMIE took the position that the allegations of the former employees fell outside of ISMIE’s policy coverage. Specifically, ISMIE argued that there were no claims alleged against Jackson involving “personal injury” caused by “professional services.” We affirm.

Jackson sought a defense and coverage from ISMIE in the United States District Court for the Southern District of Illinois from the suit brought by former employees under the False Claims Act (31 U.S.C. §3729 (2000)), for the alleged submission of false Medicare claims for reimbursement. According to the briefs of the parties, the case remained pending in the federal court as of March 2009. ISMIE filed its declaratory judgment suit in state court. At issue in this declaratory judgment is the second amended complaint. This complaint was in five counts. Count I alleged that Jackson defrauded Medicare for $78,563.40 in reimbursements during a 3.5-year period (from July 1, 1999, through December 18, 2003) by claiming to have performed 23,921 diagnostic exams called gonioscopies (tests to determine whether the area where fluid drains from the eye is damaged, blocked, or clogged) that were not actually performed. Count II alleged that between January 2001 and December 2003, Jackson falsely made Medicare claims for reimbursement of $215,208 for 10,255 extended ophthalmoscopies (to look for retinal disorders). Count III alleged that Jackson performed 2,230 medically unnecessary cataract surgeries from January 2000 and December 2003, resulting in Medicare reimbursements of $1,146,592. Count IV alleged that Jackson purposefully scheduled cataract surgical follow-ups outside of the 90-day period, which took the appointments outside of the global billing system and allowed Jackson to be able to bill separately for care that should have been inclusive with the surgical fee. Count V alleged that Jackson performed 1,314 medically unnecessary YAG capsulotomies (a laser procedure to perforate the capsule of the eye to correct a post-cataract surgical complication in which the capsule thickens) for Medicare reimbursement claims of $181,990.48 between January 2000 and December 2003.

During the years in question, Jackson was insured for medical malpractice claims with a policy issued by ISMIE. ISMIE undertook the defense of Jackson pursuant to its “Supplementary Payments” section, which provided $30,000 of coverage for claims related to Medicare investigations. The $30,000 was paid out between September 28, 2006, and August 7, 2007. On August 7, 2007, ISMIE notified Jackson that the $30,000 was almost exhausted and that no further payments would be made on Jackson’s behalf for the defense of the case. On October 5, 2007, ISMIE filed its declaratory judgment action to establish that its policy provided no additional coverage for the underlying qui torn suit.

In this declaratory judgment action, ISMIE filed a motion for a judgment on the pleadings on the basis that the Medicare fraud allegations were outside of the professional liability policy at issue. Jackson filed a summary judgment motion asserting that because the medical care at issue—the care for which his Medicare claims were being investigated—involved medical procedures (diagnostic testing and surgeries), the claims made should be covered under the malpractice coverage and not just under the Medicare investigation supplement. ISMIE filed its own summary judgment motion arguing that the damages were related to illegally obtained reimbursement monies and not to personal injury.

The “Coverage Agreement” portion of ISMIE’s policy provides as follows:

“ ‘ISMIE’ will pay amounts any ‘insured’ is legally obligated to pay as ‘damages’ because of any ‘claim’ against that ‘insured’ that is ‘first made’ to ‘ISMIE’ during the ‘policy period’ which involves ‘personal injury’ and is caused by ‘professional services’ provided on or after the ‘retroactive date’ and prior to the policy expiration date.
‘ISMIE’ has the right and duty to defend any ‘suit’ against any ‘insured’ seeking ‘damages,’ even if any of the allegations of the ‘suit’ are groundless.”

ISMIE’s medical malpractice policy defines “damages” as “monetary compensation which is owed as a result of ‘personal injury.’ ” The term “personal injury” is defined to include “bodily injury to *** any patient *** which arises out of the rendering or failure to render ‘professional services.’ ” Listed as exclusions from coverage were “Medicare Investigations.” The policy specifically excluded coverage for “liability of any ‘insured’ for actions for which criminal penalties could be assessed.” The ISMIE policy also contained a supplemental payment provision that provides as follows: “ ‘ISMIE’ will reimburse *** [a]ny ‘named insured’ for the cost of reasonable ‘legal expenses’ incurred because of a ‘Medicare Investigation’ provided always that the alleged or actual erroneous billings were submitted to the government health benefit paj^er or intermediary on or after the ‘retroactive date[ ]’ and that the ‘named insured’ had no knowledge of the ‘Medicare Investigation’ as of the inception of this policy. The maximum amount of reimbursement which may be requested by any one ‘named insured’ for any one ‘Medicare Investigation’ is $30,000 regardless of the number of policies or the number or timing of notices to ‘ISMIE.’ ”

Because the case was decided based upon the pleadings and on a summary judgment, the trial court must strictly construe all evidence in the record against the movant and liberally in favor of the opponent. Purtill v. Hess, 111 Ill. 2d 229, 240, 489 N.E.2d 867, 871 (1986). The court must consider all pleadings, depositions, admissions, and affidavits on file to decide if there is any issue of material fact. Myers v. Health Specialists, S.C., 225 Ill. App. 3d 68, 72, 587 N.E.2d 494, 497 (1992). On appeal, courts review summary judgments de novo. Myers, 225 Ill. App. 3d at 72, 587 N.E.2d at 497.

Additionally, because the construction of an insurance policy involves a question of law, we review that decision de novo. American States Insurance Co. v. Koloms, 177 Ill. 2d 473, 479-80, 687 N.E.2d 72, 75 (1997).

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Cite This Page — Counsel Stack

Bluebook (online)
921 N.E.2d 1156, 397 Ill. App. 3d 964, 337 Ill. Dec. 18, 2009 Ill. App. LEXIS 1332, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ismie-mutual-insurance-v-michaelis-jackson-associates-llc-illappct-2009.