Mary Eggiman Vs. Self-insured Services Co., And R.h. Hummer, Jr., Inc.

CourtSupreme Court of Iowa
DecidedJuly 28, 2006
Docket70 / 05-0246
StatusPublished

This text of Mary Eggiman Vs. Self-insured Services Co., And R.h. Hummer, Jr., Inc. (Mary Eggiman Vs. Self-insured Services Co., And R.h. Hummer, Jr., Inc.) is published on Counsel Stack Legal Research, covering Supreme Court of Iowa primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mary Eggiman Vs. Self-insured Services Co., And R.h. Hummer, Jr., Inc., (iowa 2006).

Opinion

IN THE SUPREME COURT OF IOWA No. 70 / 05-0246

Filed July 28, 2006

MARY EGGIMAN,

Appellant,

vs.

SELF-INSURED SERVICES CO., and R.H. HUMMER, JR., INC.,

Appellees.

________________________________________________________________________ On review from the Iowa Court of Appeals.

Appeal from the Iowa District Court for Johnson County,

Douglas S. Russell, Judge.

Plaintiff seeks further review from court of appeals decision

affirming district court order that granted defendants’ summary

judgment motion and dismissed plaintiff’s claim for benefits under a

medical insurance policy. DECISION OF COURT OF APPEALS VACATED; DISTRICT COURT ORDER REVERSED IN PART AND

REMANDED FOR FURTHER PROCEEDINGS.

Wallace L. Taylor, Cedar Rapids, for appellant.

Larry G. Gutz and Brian J. Fagan of Moyer & Bergman, P.L.C.,

Cedar Rapids, for appellees. 2 STREIT, Justice.

A woman suffering from clinical obesity alleges the company

processing claims on behalf of her health insurance plan made

misrepresentations that led her to obtain treatment not covered by the

plan. Mary Eggiman filed the present action against her husband’s

employer, R.H. Hummer, Jr., Inc., and Self-Insured Services Company

(SISCO), the claims processor for the health insurance plan. Hummer

and SISCO filed a motion for summary judgment. This motion argued

the denial of benefits was proper because Eggiman failed to obtain pre-

authorization for the surgery. The motion also argued the

misrepresentation claim against SISCO was improper because SISCO

was not a fiduciary under the Employment Retirement Income and

Security Act (ERISA). 29 U.S.C. §§ 1001, et seq. (2000). The district

court found as a matter of law it was proper to deny benefits based on

Eggiman’s failure to obtain pre-authorization. The court also concluded

SISCO was not an ERISA fiduciary and therefore could not be found

liable for any allegedly misleading statements made to Eggiman. The

court of appeals affirmed the district court ruling. On further review, we

vacate the decision of the court of appeals and reverse the portion of the

district court order which found SISCO was not an ERISA fiduciary and

therefore could not be liable for any misleading statements made to

Eggiman.

I. Background Facts and Proceedings

Eggiman suffers from clinical obesity. In 2001, her physician

recommended she consider gastric bypass surgery. Eggiman is insured

through her husband’s employer, R.H. Hummer, Jr., Inc., a trucking

firm. Hummer utilized a self-insured health and medical plan

(hereinafter “Hummer Health Plan”) as a benefit for its employees. The 3 Hummer Health Plan is governed by a “plan document” detailing the

benefits, rights, and privileges of covered individuals. In essence, the

plan document explains when the plan will pay or reimburse all or a

portion of covered expenses. SISCO marketed and sold this plan to

Hummer. SISCO is also the “claims processor” for the plan. Through a

service agreement between SISCO and Hummer, SISCO contractually

agreed to perform various functions related to the administration of the

plan. Healthcorp, Inc., SISCO’s sister company underneath the same

corporate umbrella, is listed in the plan document as the “review

organization.”

The Hummer Health Plan provides the following conditions for the

coverage of a gastric bypass procedure:

26. Charges for services in connection with surgical treatment of morbid obesity will be considered Eligible Expenses, subject to the following conditions:

a. A second concurring opinion is required prior to the surgical procedure; and

b. Pre-authorization is required.

Coverage is subject to the following guidelines:

a. Body weight must be at least 200% of the optimal weight.

b. The covered individual must have been considered morbidly obese by a Physician for at least five (5) years prior to the date surgical treatment is sought.

c. Non-surgical methods of weight reduction must have been attempted under a Physician’s supervision for at least a three (3) year period immediately prior to the date surgical treatment is sought.

On April 23, 2001, a health insurance review specialist hired by

Eggiman’s physician sent a letter to SISCO requesting a review and

authorization for the gastric bypass surgery. Among other things, the 4 physician’s health insurance review specialist informed SISCO that

Eggiman weighed 283.8 pounds and was 132.8 pounds overweight.

On May 14, 2001, the physician’s health insurance review

specialist received a letter from Cottingham & Butler (hereinafter “C&B”) 1

denying “eligibility” because the following criteria had not been met: (1)

Eggiman’s weight was less than 200% of her optimal weight, (2) there

was no documentation from a physician indicating she had been

morbidly obese for at least five years, (3) there was no documentation of

at least three years of unsuccessful physician supervised weight-loss

plans, and (4) there was no second surgical opinion.

On June 5, 2001, Eggiman received a letter from C&B, signed

HealthCorp, Inc., informing her that “hospitalization cannot be certified

due to” insufficient information. Eggiman called SISCO and spoke with a

representative about what information was still needed for certification.

On June 15, 2001, the physician’s health insurance review

specialist received another letter from C&B. This letter stated the

following criteria had been met: (1) Eggiman was considered morbidly

obese by a physician for at least the previous five years, and (2) non-

surgical methods of weight reduction had been attempted under a

physician’s supervision for at least a three year period prior to the date of

the proposed surgery. However, the letter denied “eligibility” because a

second surgical opinion had not been obtained and Eggiman’s weight

was only 188% of her ideal weight. There is no indication this letter was

sent to Eggiman.

1 C&B is the parent company of SISCO and HealthCorp. All correspondence pertinent to this claim was sent on C&B stationery. This stationery listed the names SISCO and HealthCorp under the name C&B. 5 On the same day, Eggiman received a letter from C&B, signed

HealthCorp. Inc., that stated:

[Mary Eggiman] has been pre-certified for a GASTRIC BYPASS FOR OBESITY by HealthCorp, the managed care company selected by your employer. At this time a date has not been established for the procedure. HealthCorp should be notified . . . when a date is confirmed.

The physician, SISCO, and the hospital have been notified of your certification. IT DOES NOT GUARANTEE PAYMENT.

Healthcorp’s certification process evaluates the appropriate length of hospital stay and/or the appropriateness of services provided. Please be advised that the determination of your benefits will be decided by the rules within your company’s health plan document. Any reimbursement is based on the services that were provided, the participant’s eligibility and the plan limitations.

(Emphasis in original.)

On July 24, 2001, Eggiman received another letter from C&B,

signed by HealthCorp. Inc. The letter stated the following:

This letter is to notify you that your upcoming hospitalization, listed above, has been precertified.

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