Medical Mutual of Ohio v. k. Amalia Enterprises Inc.

CourtCourt of Appeals for the Sixth Circuit
DecidedDecember 2, 2008
Docket07-4422
StatusPublished

This text of Medical Mutual of Ohio v. k. Amalia Enterprises Inc. (Medical Mutual of Ohio v. k. Amalia Enterprises Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Medical Mutual of Ohio v. k. Amalia Enterprises Inc., (6th Cir. 2008).

Opinion

RECOMMENDED FOR FULL-TEXT PUBLICATION Pursuant to Sixth Circuit Rule 206 File Name: 08a0436p.06

UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT _________________

X Plaintiff-Appellant, - MEDICAL MUTUAL OF OHIO, - - - No. 07-4422 v. , > k. AMALIA ENTERPRISES INC., et al., - Defendants-Appellees. - N Appeal from the United States District Court for the Southern District of Ohio at Columbus. No. 05-00381—Michael H. Watson, District Judge. Argued: July 24, 2008 Decided and Filed: December 2, 2008 Before: MOORE and SUTTON, Circuit Judges; ALDRICH, District Judge.* _________________ COUNSEL ARGUED: Timothy B. Pettorini, CRITCHFIELD, CRITCHFIELD & JOHNSTON, LTD., Wooster, Ohio, for Appellant. Christopher L. Lardiere, LARDIERE LAW OFFICES, LLC, Columbus, Ohio, Joel H. Mirman, ADAMS, BABNER & GITLITZ, LLC, Columbus, Ohio, for Appellees. ON BRIEF: Timothy B. Pettorini, David J. Wigham, CRITCHFIELD, CRITCHFIELD & JOHNSTON, LTD., Wooster, Ohio, for Appellant. Christopher L. Lardiere, LARDIERE LAW OFFICES, Columbus, Ohio, Joel H. Mirman, ADAMS, BABNER & GITLITZ, LLC, Columbus, Ohio, Stephen E. Chappelear, Jeffrey A. Yeager, HAHN, LOESER & PARKS, L.L.P., Columbus, Ohio, for Appellees. _________________ OPINION _________________ KAREN NELSON MOORE, Circuit Judge. Plaintiff-Appellant Medical Mutual of Ohio (“MMO”), an insurance company, brought suit against Loan A. Tran (“Tran”) and Khanh B. Luu (“Luu”) for failing to disclose that their dependent son had a preexisting medical condition (hemophilia). MMO also included as defendants Tran’s employer, k. Amalia Enterprises Inc. (“k. Amalia”), which contracted with MMO to provide group health insurance, and k. Amalia’s Chief Financial Officer, John M. Barr (“Barr”), who signed the group-health-insurance contract on behalf

* The Honorable Ann Aldrich, United States District Judge for the Northern District of Ohio, sitting by designation.

1 No. 07-4422 Medical Mutual of Ohio v. k. Amalia Enterprises Inc. et al. Page 2

of k. Amalia. MMO appeals the district court’s grant of summary judgment to k. Amalia, Barr, Tran, and Luu. Because all of MMO’s claims are barred by a contractual limitations provision, we AFFIRM the district court’s grant of summary judgment to k. Amalia, Barr, Tran, and Luu and AFFIRM the district court’s denial of MMO’s motion for reconsideration. I. BACKGROUND A. Factual Background Barr, k. Amalia’s Chief Financial Officer, contracted with MMO to provide a group-health- insurance plan. He signed the Group Application on October 20, 2001. MMO agreed to cover k. Amalia’s employees from November 1, 2001, to October 31, 2002; they renewed the contract in 2002, but did not renew it in 2004. As part of the contract, MMO required k. Amalia employees to complete Medical History Questionnaires if they wished to be covered by the group-health-insurance plan. Tran, an employee,1 and her husband completed and signed the “Health and Life Application/Policy Change” form on October 14, 2001. Joint Appendix (“J.A.”) at 139-41 (Pl.’s Mot. for Leave to Substitute Original Aff., Ex. A-1). The application submitted by Tran stated that neither Tran nor her dependents had currently (or had previously had) any of the medical conditions listed on the form, including hemophilia. Tran also checked a box indicating that neither she nor her dependents “had, or [had] been treated for, or been told that” they had “any other condition/disorder/disease” that was not listed explicitly on the form. J.A. at 140 (Pl.’s Mot. for Leave to Substitute Original Aff., Ex. A-1). A member of the Financial Investigations Department for MMO stated in his affidavit that “MMO assessed its risk, determined its rates, and issued the group contract for health insurance to the K. Amalia group in reliance upon the truth and accuracy of the information in the applications.” J.A. at 137 (Pl.’s Mot. for Leave to Substitute Original Aff., Ex. A, Ferrara Aff. ¶ 5). The contract gave MMO “the right to void a Covered Person’s coverage if that person engages in fraudulent conduct relating to an Application.” J.A. at 106 (Contract at § 5.5). The contract also contained the following contractual limitations provision: No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty (60) days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three (3) years after the time written proof of loss is required to be furnished. In the case of legal action other than those to recover benefits, no such action may be brought more than two (2) years from the date the cause of action arises. J.A. at 105 (Contract at § 5.3). In August 2004, MMO conducted an audit that revealed Tran’s dependent son, Hiep Luu, had a pre-existing condition—hemophilia—that had not been disclosed on the insurance application. MMO admits that it knew Hiep Luu had hemophilia “on or before February 1, 2002,” but claims that it did not know that this was a pre-existing condition. J.A. at 92 (Req. for Admis. No. 27). MMO estimates that it paid approximately $525,000 for claims related to Hiep Luu’s treatment before it realized that he had been diagnosed with hemophilia before Tran completed the MMO insurance application.

1 Tran worked for MJR International, which was affiliated with k. Amalia. There was one group-health plan for both companies. No. 07-4422 Medical Mutual of Ohio v. k. Amalia Enterprises Inc. et al. Page 3

“MMO processes approximately 102,000 claims per day and has approximately 1.6 million subscribers.” J.A. at 138 (Pl.’s Mot. for Leave to Substitute Original Aff., Ex. A, Ferrara Aff. ¶ 9). MMO admits that some of the claims filed on behalf of Hiep Luu referred to a treatment/drug known as “Factor VIII (Antihemophilic Factor, Recombinant), per IU,” J.A. at 88 (Req. for Admis. No. 9), and that “it had access to the procedure code prescription/drug name . . . when it decided whether to pay or deny the claims,” J.A. at 92 (Req. for Admis. No. 25). Also, MMO admits that “an ‘antihemophilic’ treatment would be administered to an individual afflicted by hemophilia,” J.A. at 91 (Req. for Admis. No. 23), and that it paid a claim for such a treatment in February 2002. J.A. at 88-89 (Req. for Admis. No. 11). Finally, MMO admits that it had never informed k. Amalia or Barr of Hiep Luu’s medical-claims history. B. Procedural Background MMO filed suit against k. Amalia, Barr, Tran, and Luu on April 14, 2005. In its Complaint, MMO alleged that Tran, Luu, k. Amalia, and Barr breached the insurance contract, made negligent misrepresentations, and engaged in fraudulent behavior. MMO sought compensatory damages for these claims. MMO also sought partial rescission of the contract, as it related to health-insurance coverage of Tran and her dependents. For this claim, MMO requested that the court provide “restitution . . . in an amount to be determined at trial, but believed to exceed $500,000.00, plus interest, attorney fees and court costs.” J.A. at 23 (Compl. ¶ 69). Finally, MMO brought a claim against Tran and Luu, alleging that they had been unjustly enriched by their failure to disclose their son’s condition and seeking compensatory damages. K. Amalia filed an answer that included counterclaims alleging that the litigation was “frivolous,” that MMO had tortiously interfered with k. Amalia’s current and future contractual relations, that MMO had negligently handled “the analysis and payment of claims,” and that MMO had breached its contract with k. Amalia. J.A. at 52 (Answer and Countercl. at 17). K. Amalia sought compensatory damages in excess of $50,000.00 on its counterclaims. K. Amalia, Barr, Tran, and Luu filed a joint motion for summary judgment on July 24, 2006, claiming that MMO had failed to file its suit within the contractual limitations period.

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Medical Mutual of Ohio v. k. Amalia Enterprises Inc., Counsel Stack Legal Research, https://law.counselstack.com/opinion/medical-mutual-of-ohio-v-k-amalia-enterprises-inc-ca6-2008.