Mauer v. Board of Trustees of the Missouri State Employees' Retirement System

762 S.W.2d 517, 1988 Mo. App. LEXIS 1736, 1988 WL 134966
CourtMissouri Court of Appeals
DecidedDecember 20, 1988
DocketNo. WD 40489
StatusPublished
Cited by9 cases

This text of 762 S.W.2d 517 (Mauer v. Board of Trustees of the Missouri State Employees' Retirement System) is published on Counsel Stack Legal Research, covering Missouri Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mauer v. Board of Trustees of the Missouri State Employees' Retirement System, 762 S.W.2d 517, 1988 Mo. App. LEXIS 1736, 1988 WL 134966 (Mo. Ct. App. 1988).

Opinion

GAITAN, Judge.

This is an appeal by the Missouri State Employees’ Retirement System (MOSERS), appellant, from a summary judgment granted in favor of William F. Mauer, respondent, in a suit to determine the correct payment of benefits under the MOSERS Medical Care Plan. Appellant alleges that the trial court erred on four points: (1) in granting summary judgment when there were genuine issues of fact in controversy, and a defective affidavit in support of the Motion for Summary Judgment did not render facts admitted; (2) the basis of denial of respondent’s claim did not change and there was no detriment to the respondent in pursuing his remedies and the court erred in so finding; (3) in awarding either the return of the cost of the Peer Review Group or prejudgment interest to respondent; and (4) in assessing the cost of the action against MOSERS when costs cannot be assessed against the state or its agencies.

Appellant, MOSERS, is the statutory system authorized by law to provide retirement benefits, a medical care plan and insurance benefits to Missouri state employees, elected officials and their dependents. The particular statute applicable to the Medical Care Plan is § 104.515, RSMo 1986.

Respondent is a Jackson County Circuit Court Judge and is a member of MOSERS. He has provided under the Medical Care Plan for his wife, Pamela Mauer, whose claim is the subject of this litigation. On September 17,1985, Mrs. Mauer underwent surgery for an abdominal hysterectomy, oophorectomy and appendectomy. Her claim for benefits was submitted on October 14, 1985 based on surgical charges as follows: $1500 for the abdominal hysterectomy; $275 for the oophorectomy; and $225 for the appendectomy. Since the surgery occurred in the Kansas City area, the claims were processed by MOSERS based on reasonable and customary allowances in Kansas City.

As a result of processing the claim, MOS-ERS paid the full charges for the oophorec-tomy and appendectomy, but the abdominal hysterectomy was partially paid. The explanation of benefits form stated the reason of the non-covered hysterectomy charge was that “benefits are limited to reasonable and customary allowances.” There was no other explanation for the non-covered charge until respondent received a review letter from the Peer Review Group dated May 21, 1986. In that letter it stated that: “the charge for the oophorectomy, which was separately charged and paid by your plan, is generally included in the charge for the hysterectomy. ... The reviewing physician felt the appendectomy was incidental and questioned whether it merited a separate charge. However, $1500 for an abdominal hysterectomy is considered usual and customary in the Kansas City area.”

A Petition was filed in the Circuit Court of Cole County on December 11, 1986, against the Board of Trustees, along with the individually named members, seeking the difference between what was paid by MOSERS for the claim and the total bill, plus attorney’s fees and costs. A First Amended Petition was filed on March 19, 1987, seeking the same relief but adding a claim for William Mauer as Count II. The claim relating to Count II was resolved and paid, and a Second Amended Petition was [519]*519filed dismissing Count II and clarifying the names of the appropriate Board members.

In both the Petition and First Amended Petition respondent claimed that appellants are estopped from changing their first position stated in the reason for not allowing total coverage of the abdominal hysterectomy and relying on a different defense in the letter from the Peer Group Review. An Answer was filed by MOSERS reiterating its position that if all procedures were included in the total charge of $1500, it would not be in excess of the usual and customary charges for an abdominal hysterectomy. However, MOSERS stated that where the procedures were billed separately, as in this instance, the total charges exceed the usual and customary charges for an abdominal hysterectomy in the Kansas City area. MOSERS stated that complete and full payment had been made under the provision of the Medical Care Plan.

Respondent filed a Motion for Summary Judgment on September 8, 1987. In the motion it was asserted that there were no genuine issues as to any material fact and that there was a departure of defenses by MOSERS in that the separate charges for the oophorectomy and appendectomy in addition to charges for the hysterectomy exceeded the usual and customary charges for such surgery in the Kansas City area. Summary judgment was granted in the amount of $466.00 plus $57.87 (the cost of Peer Group Review), plus interest in the amount of $84.91 for a total of $608.78, plus costs.

Appellant contends that the statement labeled as an affidavit submitted in support of the motion for summary judgment was defective, thereby the facts in the motion could not be rendered admitted. Also, in the same vein, appellant contends that the granting of respondent’s motion for summary judgment was in error.

Rule 74.04(a) states that a party may “move with or without supporting affidavits for a summary judgment in his favor upon all or any part” of his claim. Additionally, a summary judgment may rest upon the pleadings alone. Pennell v. Polen, 611 S.W.2d 323 (Mo.App.1980) (citing Sam Kraus Company v. State Highway Commission, 416 S.W.2d 639, 641[1] (Mo.1967)).

In the case at bar, the alleged affidavit is nothing more than a declaration of information contained in the motion. It is not an affidavit in the true sense of the word. Nonetheless, the alleged affidavit is not a requisite for a ruling upon a motion for summary judgment. Rule 74.04(a). The granting of a motion, as in the case at bar, may be based upon the pleadings alone. The motion here does not encompass matters outside the pleading, and all facts alleged in the motion are facts admitted by appellant in the pleadings and in the suggestions in opposition to the motion for summary judgment. Therefore, the defectiveness of the alleged affidavit is insignificant.

Regardless of the form of the alleged affidavit, the granting of summary judgment is a drastic remedy. Kennon v. Citizens Mutual Insurance Company, 666 S.W.2d 782, 784 (Mo.App.1983). Summary judgment is only appropriate if the prevailing party has shown by unassailable proof to be entitled thereto as a matter of law. Id. In reviewing a grant of summary judgment, this Court “must scrutinize the record in the light most favorable to the party against whom summary judgment was rendered.” Id. The party who was granted summary judgment must show “that under no discernable circumstances could the opposing party be entitled to recover.” Bakewell v. Missouri State Employees’ Retirement, 668 S.W.2d 224, 229 (Mo.App.1984).

In the case at bar, the question is whether appellant, having once denied coverage, later asserted denial of coverage based upon other grounds. The law is clear that once liability is denied on one basis, the insured has relied to his detriment by preparing to meet the defense asserted, the insurer waives all other defenses to the claim asserted. Lawrence v. New York Life insurance Co.,

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Bluebook (online)
762 S.W.2d 517, 1988 Mo. App. LEXIS 1736, 1988 WL 134966, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mauer-v-board-of-trustees-of-the-missouri-state-employees-retirement-moctapp-1988.