Mortgage Lenders Network USA, Inc. v. CoreSource, Inc.

335 F. Supp. 2d 313, 34 Employee Benefits Cas. (BNA) 1599, 2004 U.S. Dist. LEXIS 18692, 2004 WL 2093506
CourtDistrict Court, D. Connecticut
DecidedSeptember 16, 2004
Docket3:03CV1578(JBA)
StatusPublished
Cited by7 cases

This text of 335 F. Supp. 2d 313 (Mortgage Lenders Network USA, Inc. v. CoreSource, Inc.) is published on Counsel Stack Legal Research, covering District Court, D. Connecticut primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mortgage Lenders Network USA, Inc. v. CoreSource, Inc., 335 F. Supp. 2d 313, 34 Employee Benefits Cas. (BNA) 1599, 2004 U.S. Dist. LEXIS 18692, 2004 WL 2093506 (D. Conn. 2004).

Opinion

Ruling on Motion to Dismiss [Doc. # 15]

ARTERTON, District Judge.

Plaintiff, Mortgage Lenders Network USA, LLC (“MLN”), the Plan Sponsor and Plan Administrator of a self-funded employee benefit health plan, brought suit against defendant CoreSource, the Plan Supervisor, alleging breach of contract, breaches of ERISA and common law fiduciary duties, and negligence. Defendant CoreSource has moved to dismiss the second count of plaintiffs complaint, on grounds that plaintiff has failed to state a claim for relief under both ERISA and common law fiduciary duty theories. For the reasons discussed below, defendant’s motion is granted in part and denied in part.

I. Background

In April 1999, MLN adopted its self-funded employee benefit health plan (“MLN Plan”) and entered into an agreement with CoreSource, making Core-Source the Plan Supervisor charged with performing certain services for the claims administration and operation of the MLN Plan. See First Amended Complaint [Doc. # 12] at ¶¶ 8-9. For example, CoreSource was required to “review claims for benefits,” to “provide an appropriate check and explanation of benefits, and when appropriate, deny claims not eligible,” to “communicate with physicians, hospitals, and other third party providers ... in order to clarify or verify benefits or claims,” and to “advise [MLN] as to payments required to be made.” See id. at ¶ 12 (quoting Agreement for Plan Supervisor [Doc. # 12, Ex. A] at ¶ 3.04). While MLN thereby delegated much of the responsibility for claim processing to CoreSource, MLN retained “final authority to decide the insurance (or reinsurance) company or companies chosen under the Plan, and to choose the benefits *315 and other provisions in the Plan Document.” Agreement for Plan Supervisor [Doc. # 12, Ex. A] at ¶ 2.06. Section VII of the Agreement also provided that MLN retained ultimate authority for determinations as to benefit payments, and that “for the purposes of ERISA and any applicable State legislation of similar nature,” MLN shall be deemed the Plan Administrator. Id. at ¶7.01. Further, the Agreement provided that CoreSource, “in performing its obligations under this Agreement is acting only as an agent of the Company, and shall not for any purpose be deemed an employee of MLN or a fiduciary of the Plan.” Id.

Under the terms of the MLN Plan, non-experimental, medically necessary procedures were covered, but experimental procedures, such as those that were still under study or the subject of ongoing Phase I, II, or III clinical trials, were exempted from coverage. See First Amended Complaint [Doc. # 12] at ¶¶ 15-16; MLN Plan [Doc. # 12, Ex. B].

MLN purchased stop-loss insurance from Clarendon National Insurance Company (“Clarendon”), in which Clarendon agreed to pay for all medical benefits established under MLN’s Plan, except for “expenses which are not medically necessary or are in excess of [MLN’s] Plan benefits,” and “expenses resulting from experimental/investigational medical practices or procedures or for any care, medicine, services, or supplies not considered legal in the United States.” First Amended Complaint [Doc. # 12] at ¶ 20.

In July 2001, Alyssa Koski, the three year old daughter of MLN employee James Koski and a covered person under the MLN Plan, was diagnosed with Stage IV neuroblastoma. See id. at ¶¶ 24, 26. After Alyssa Koski was evaluated and accepted for a triple autologous peripheral stem cell transplant at Children’s Memorial Hospital in Chicago, CoreSource retained an independent physician to review the proposed treatment in order to determine whether the proposed treatment was covered under the MLN Plan. See id. at ¶¶ 28-29. On or about October 22, 2001, the independent physician informed Core-Source that the treatment was medically necessary, but was considered investiga-tional and/or experimental, because it was in a Phase II Clinical Trial period and was not considered the standard of care. See id. at ¶ 30. CoreSource therefore advised MLN that the proposed treatment would not be covered under the MLN Plan. On October 23, 2001, CoreSource requested that New York Underwriters, the managing general underwriter for Clarendon, review whether Alyssa Koski’s proposed treatment was covered under the Stop Loss Agreement. See id. at ¶ 32. Core-Source was informed by New York Underwriters on October 30, 2001 that the proposed treatment was not covered under the Stop Loss Agreement, and in November 2001, CoreSource advised MLN of New York Underwriters’ decision. See id. at ¶¶ 34, 35. In November 2001, Alyssa Koski’s father appealed CoreSource’s determination, and CoreSource retained a second independent physician. Although the second independent physician initially agreed that the proposed treatment was considered experimental, after conferring with Alyssa Koski’s attending physician and receiving supplemental information, the second independent physician amended his opinion and reported that the proposed treatment was no longer considered experimental because the clinical trials for the procedure had been concluded and a manuscript detailing the results of the study had been approved for publication. See id. at ¶¶ 38-41.

On November 26, 2001, CoreSource requested that New York Underwriters review the amended opinion of the second independent physician. After reviewing *316 the opinion, New York Underwriters informed CoreSource on December 18, 2001 that it had not changed its position that Alyssa Koski’s proposed treatment was “experimental / investigational,” and therefore not covered under the Stop Loss Agreement. See id. at ¶¶ 42^43. According to plaintiffs complaint, CoreSource did not inform MLN' of the decision of New York Underwriters. 'See id. at ¶ 44.

On or about January 11, 2002, New York Underwriters informed CoreSource that it would provide coverage to MLN for a single transplant arid two chemotherapy sessions, but that additional stem cell support therapies would not be covered. See id. at ¶ 45. After again discussing with CoreSource the findings of CoreSource’s second independent physician, on or about January 17, 2002, New York Underwriters agreed to further review the case with Clarendon. See id. at ¶ 47. On the same day, CoreSource informed MLN that MLN had a viable claim for coverage under the Stop Loss Agreement based on the opinion of its second independent physician, which relied on the anticipated publication of a new study detailing the results of a clinical trial of the proposed treatment for Alyssa Koski. See id. at ¶ 48. Based on the information CoreSource provided, MLN approved Alyssa Koski’s triple auto-logous peripheral stem cell transplant, and on January 21, 2002, Alyssa Koski underwent this procedure. See id. at ¶¶ 58-59.

On January 25, 2002, New York Underwriters again informed CoreSource that it viewed the treatment as “experimental/in-vestigational” under the Stop Loss Agreement. On February 14, 2002, CoreSource provided MLN with copies of the clinical study, the article for publication, and New York Underwriters’ January 25, 2002 denial of coverage. See id. at ¶ 61.

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335 F. Supp. 2d 313, 34 Employee Benefits Cas. (BNA) 1599, 2004 U.S. Dist. LEXIS 18692, 2004 WL 2093506, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mortgage-lenders-network-usa-inc-v-coresource-inc-ctd-2004.