Jones v. State Wide Aluminum, Inc.

246 F. Supp. 2d 1018, 30 Employee Benefits Cas. (BNA) 1039, 2003 U.S. Dist. LEXIS 2962, 2003 WL 554540
District Court, N.D. Indiana·Decided February 20, 2003·No. 3:02-cv-00228·Published

Opinion

MEMORANDUM AND ORDER

MILLER, District Judge.

Doctors diagnosed Tom Ray Jones with leukemia on March 4, 2001. This sad discovery touched off a legal dispute over who would fund Mr. Jones’s fight against the disease (a fight he lost on August 6, 2002). Mr. Jones was covered by two ERISA qualified health plans, State Wide, 1 and Partners, an HMO, each of which decided the other was obligated to pay. At the heart of the dispute is an escape clause in State Wide’s plan that absolves it of the duty to pay a plan member’s health care costs if that person is also covered by, and receives treatment through, an HMO. Partners and Mrs. Jones 2 say federal common law has banished this clause from the ERISA world. State Wide takes a different view. Before the court resolves this dispute, it faces the issue of exhaustion— whether the plaintiff needed to exhaust her internal plan remedies before bringing suit against State Wide, and if so, whether she did so. 3 For the reasons stated below, the court finds that the exhaustion requirement applied and was unfulfilled and that the court should not create federal common law to stamp out the escape clause.

Facts

Mr. and Mrs. Jones applied to both State Wide and Partners for reimbursement for their mounting medical bills. State Wide paid these bills initially, but decided on further review that the escape clause applied to Mr. Jones’s situation. Beginning on May 31, 2001, State Wide ceased paying Mr. Jones new medical bills and began contacting those it had already paid in search of refunds. State Wide’s change of heart prompted the Joneses to *1022 reapply to Partners. At the outset, Partners warmly received this new application and started paying Mr. Jones’s bills. Like State Wide before it, though, Partners had a change of heart and stopped paying Mr. Jones’s bills.

Partners became convinced for two reasons that State Wide owed Mr. Jones for these bills. First, both plans had a coordination of benefits clause-language in a health care plan that addresses coordination of coverage with another plan when both plans cover the same person-that called on the employer’s plan to be the primary payor in the case of dual coverage. That was State Wide. Second, Partners thought that the escape clause, which otherwise would trump the choice of benefits clauses, was illegal and unenforceable ab initio. The escape clause reads, “[i]f you and/or your eligible dependents while covered under this plan [sic] are also covered under an HMO (Health Maintenance Organization) provided by another employer and receive treatment through the HMO provider, no benefits will be payable for such treatment under this Plan.” State Wide Plan at 26 (attached as exhibit A to Plaintiffs’ Motion for Partial Summary Judgment).

Mrs. Jones sued both plans under a variety of legal theories 4 and moved for summary judgment against both plans. She bases her summary judgment motion against State Wide on the unenforceability of the escape clause and waiver; she says that by paying some of Mr. Jones’s bills before deciding that the escape clause applied, State Wide had waived its right to deny Mr. Jones coverage. Her summary judgment against Partners simply asks the court to declare that Partners owes her coverage regardless of the court’s ruling on the escape clause because Partners has a secondary coverage clause indicating that it will pay the excess amount not covered by the other plan in the event of dual coverage. That is, if the escape clause is enforceable, Partners is on the hook as the primary payor, and if the clause is not enforceable, Partners’ responsibility is simply that of a secondary payor.

State Wide and Partners did not sit idly. Partners lodged a cross claim against State Wide for a declaratory judgment invalidating the escape clause, and later sought judgment on the pleadings on its cross claim. State Wide responded with a summary judgment motion against Partners on the declaratory judgment cross-claim. Also pending are a motion for oral argument and a motion urging the court to consider Partners’ motion for judgment on the pleadings only after all of the other motions were fully briefed.

Exhaustion

Although much turns on the court’s view of the escape clause, the court begins with Mrs. Jones’s summary judgment motion against State Wide first because that motion raises the issue of exhaustion. Summary judgment for Mrs. Jones would be proper if “the pleadings, depositions, answers to the interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue of material fact and that the moving party is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(c). In deciding whether a genuine issue of material fact exists, the court construes all facts in the light most favorable to the nonmoving party and draws all reasonable inferences in that party’s favor. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 106 S.Ct. 2505, 91 *1023 L.Ed.2d 202 (1986). No genuine issue of material fact exists when a rational trier of act could not find for the nonmoving party even when the record as a whole is viewed in the light most favorable to the non-moving party. Ritchie v. Glidden Company, 242 F.3d 713, 720 (7th Cir.2001). “[N]either the mere existence of some alleged factual dispute between the parties, nor the existence of some metaphysical doubt as to material facts is sufficient to defeat such a [summary judgment] motion.” Holtz v. J.J.B. Hilliard, W.L. Lyons, Inc., 185 F.3d 732, 738 (7th Cir.1999) (internal citations and quotations omitted).

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Jones v. State Wide Aluminum, Inc., 246 F. Supp. 2d 1018, 30 Employee Benefits Cas. (BNA) 1039, 2003 U.S. Dist. LEXIS 2962, 2003 WL 554540 (N.D. Ind. 2003).

246 F. Supp. 2d 1018 (Jones v. State Wide Aluminum, Inc.) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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