Jane Tomczyk v. Blue Cross & Blue Shield United of Wisconsin

951 F.2d 771, 21 Fed. R. Serv. 3d 1292, 1991 U.S. App. LEXIS 30199, 1991 WL 276197
CourtCourt of Appeals for the Seventh Circuit
DecidedDecember 30, 1991
Docket91-1018
StatusPublished
Cited by26 cases

This text of 951 F.2d 771 (Jane Tomczyk v. Blue Cross & Blue Shield United of Wisconsin) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Jane Tomczyk v. Blue Cross & Blue Shield United of Wisconsin, 951 F.2d 771, 21 Fed. R. Serv. 3d 1292, 1991 U.S. App. LEXIS 30199, 1991 WL 276197 (7th Cir. 1991).

Opinion

PER CURIAM.

Jane Tomczyk brought this action against Blue Cross and Blue Shield United of Wisconsin (Blue Cross), a Wisconsin nonprofit corporation, alleging ERISA, state common-law, and constitutional violations. The District Court granted summary judgment to Blue Cross on the ERISA count, and dismissed the others. Tomczyk appeals the disposition of her ERISA and state common-law claims. We affirm. Moreover, because of the largely frivolous nature of this appeal, as well as the misleading manner in which it was presented to this Court, we impose Rule 38 sanctions on Tomczyk's attorneys, Marjan Kmiec and Christopher McConville of Kmiec Law Offices.

I.

Jane Tomczyk is a member of an ERISA-regulated group health insurance plan issued by Blue Cross and sponsored by her employer. After undergoing oral surgery on October 3, 1987, she filed a claim with Blue Cross for reimbursement of approximately $8,250 in surgical and hospital fees. *773 Blue Cross denied the claim. Tomczyk sued Blue Cross under ERISA for denial of benefits, see 29 U.S.C. § 1132(a)(1)(B), (a)(3), brought state common-law claims of bad faith, breach of contract, and tortious interference with her contractual relationship with her doctor, and asserted a constitutional claim under 42 U.S.C. § 1983. She sought reimbursement of her medical costs, as well as extra-contractual compensatory and punitive damages.

The District Court dismissed the state common-law claims as preempted by ERISA, and the § 1983 claim owing to a lack of state action. See Tomczyk v. Blue Cross & Blue Shield United of Wisconsin, 715 F.Supp. 914, 918 (E.D.Wis.1989). In a separate decision granting Blue Cross summary judgment on the ERISA claim, the court determined that no genuine issue of material fact existed and found that Blue Cross had properly denied benefits to Tomczyk under the terms of the contract. See Tomczyk v. Blue Cross & Blue Shield United of Wisconsin, No. 88-C-690, slip op. at 13 (E.D.Wis. Dec. 6, 1990). Tomczyk appeals the grant of summary judgment to Blue Cross on the ERISA claim, and the dismissal of her state common law and extra-contractual damage claims. We first examine her ERISA claim.

A.

We review de novo the District Court’s grant of summary judgment to Blue Cross. See Doe v. Allied-Signal, Inc., 925 F.2d 1007, 1008 (7th Cir.1991). Summary judgment must be granted if the pleadings and supporting documents “show there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(c). We must view the record and all inferences drawn from it in the light most favorable to the nonmoving party. See Lohom v. Michal, 913 F.2d 327, 331 (7th Cir.1990). The nonmoving party, however, may not rest on its pleadings, and must demonstrate, with specific evidence, that a genuine issue of triable fact remains. See Celotex Corp. v. Catrett, 477 U.S. 317, 324, 106 S.Ct. 2548, 2553, 91 L.Ed.2d 265 (1986).

The District Court concluded that the oral surgery performed on Tomczyk was not a covered procedure under her insurance plan. Tomczyk has not appealed the court’s de novo interpretation of the insurance contract. See Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 955, 103 L.Ed.2d 80 (1989) (courts must review denial of ERISA plan benefits de novo unless the plan gives the administrator discretionary authority to determine benefit eligibility or to construe doubtful or contested terms, in which case the arbitrary and capricious standard applies). Rather, Tomczyk claims that the court should not have granted summary judgment because whether Blue Cross authorized her medical expenses is a disputed factual issue. We disagree.

Tomczyk receives her insurance coverage through the Blue Cross “Advantage Program.” Under this program, certain requirements must be met before a plan member may receive full benefits for covered services for nonemergency inpatient hospital care. Blue Cross must determine that the hospitalization is medically necessary and authorize the care. Additionally, the member must notify Blue Cross prior to admission that hospitalization is anticipated, and a length of stay must be authorized. The contract provides that, “[i]f the admission was not preauthorized, benefits will be limited to 80% of the amount otherwise allowed according to the contract provisions for covered benefits.” Exhibit A, Section MC, at 74. Moreover, the contract states that even where the hospital stay is preauthorized, “[ojther limitations, exclusions and conditions of the contract are not affected by this section and still apply.” Id.

Tomczyk first consulted with John Goeckerman, D.D.S., who subsequently performed the surgery on her jaw, on September 21, 1987. Dr. Goeckerman determined that Tomczyk required corrective treatment consisting of two variations of a surgical procedure known as “osteotomy of the temporo mandibular joint.” On September 30, an employee with Dr. Goecker-man’s office called Blue Cross’s Advantage *774 Program and spoke to Elise McKinch, R.N., a “Managed Care Specialist” who reviews inpatient hospital admissions and authorizes lengths of stay. Tomczyk contends that Blue Cross authorized her October 3 surgery in that telephone conversation.

In her brief, Tomczyk claims that McKinch told Dr. Goeckerman’s office that her “insurance was in ‘perfect standing’ ” and that Blue Cross “would cover all medical costs regarding Jane Tomczyk’s medically necessary surgery, thereby approving said surgical treatments.” Appellant’s Br. at 5-6. Nowhere does the record support such an assertion. The sole piece of evidence Tomczyk cites in this regard is Dr. Goeckerman’s affidavit. That affidavit, however, states only that McKinch had told his office that Blue Cross “had authorized the hospital stay for the intended surgery,” Goeckerman Affidavit at 1, an assertion Blue Cross does not dispute. According to McKinch’s affidavit, she informed Dr. Goeckerman’s office that she “would authorize a three day inpatient hospital stay.” McKinch Affidavit at 2. Significantly, however, her affidavit also states that she informed Dr. Goeckerman’s office “that the authorization related to the patient’s need to have the procedures done as an inpatient and was not an authorization of coverage,” id., and “that it would be advisable to get verification of coverage from Blue Cross’ Medical Review department.” Id. Additionally, because she had determined, and informed Dr. Goeckerman’s office, that the procedure might not be covered, she did not send the customary letter confirming admission preauthorization. Id.

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

Related

Woods v. City of Hammond
N.D. Indiana, 2020
Minger v. Berryhill
307 F. Supp. 3d 865 (E.D. Illinois, 2018)
Minger v. Berryhill
N.D. Illinois, 2018
New v. Verizon Communications, Inc.
635 F. Supp. 2d 773 (N.D. Illinois, 2008)
Neuma, Inc. v. EI DuPont De Nemours and Co.
133 F. Supp. 2d 1082 (N.D. Illinois, 2001)
Harris v. Franklin-Williamson Human Services, Inc.
97 F. Supp. 2d 892 (S.D. Illinois, 2000)
Reber v. Provident Life & Accident Insurance
93 F. Supp. 2d 995 (S.D. Indiana, 2000)
Cleveland Hair Clinic, Inc. v. Puig Medical Group, S.C.
200 F.3d 1063 (Seventh Circuit, 2000)
Cleveland Hair Clinic, Inc. v. Puig
200 F.3d 1063 (Seventh Circuit, 2000)
Cozzie v. Metropolitan Life Insurance
963 F. Supp. 647 (N.D. Illinois, 1997)
Cronin v. Town of Amesbury
81 F.3d 257 (First Circuit, 1996)
Goldberg v. Prudential Insurance Co. of America
892 F. Supp. 202 (N.D. Illinois, 1995)
Hemphill v. Unisys Corp.
855 F. Supp. 1225 (D. Utah, 1994)
Linda Swerhun v. The Guardian Life Ins. Co. Of America
979 F.2d 195 (Eleventh Circuit, 1992)
Talamine v. Unum Life Insurance Co. of America
803 F. Supp. 198 (N.D. Illinois, 1992)

Cite This Page — Counsel Stack

Bluebook (online)
951 F.2d 771, 21 Fed. R. Serv. 3d 1292, 1991 U.S. App. LEXIS 30199, 1991 WL 276197, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jane-tomczyk-v-blue-cross-blue-shield-united-of-wisconsin-ca7-1991.