Mutual Medical Plans, Inc. v. County of Peoria

309 F. Supp. 2d 1067, 33 Employee Benefits Cas. (BNA) 1369, 2004 U.S. Dist. LEXIS 4059, 2004 WL 504678
CourtDistrict Court, C.D. Illinois
DecidedMarch 16, 2004
Docket01-1469
StatusPublished
Cited by4 cases

This text of 309 F. Supp. 2d 1067 (Mutual Medical Plans, Inc. v. County of Peoria) is published on Counsel Stack Legal Research, covering District Court, C.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mutual Medical Plans, Inc. v. County of Peoria, 309 F. Supp. 2d 1067, 33 Employee Benefits Cas. (BNA) 1369, 2004 U.S. Dist. LEXIS 4059, 2004 WL 504678 (C.D. Ill. 2004).

Opinion

ORDER

MIHM, District Judge.

Before the Court is Defendant Frank Walter’s Motion for Summary Judgment [# 86]. For the following reasons, the Motion is GRANTED. The Court declines to retain jurisdiction over the state law Counter-Claim and, therefore,, it is DISMISSED without prejudice so that it may be re-filed in state court.

*1070 Background

This case arises out of the criminal investigation and prosecution of Plaintiff, Ron Jones (“Jones”), the owner and president of Mutual Medical Plans, Inc. (“Mutual Medical” or “The Company”). Mutual Medical is an Illinois corporation whose primary business is the third party administration of employer-sponsored health benefit plans. Kevin Lyons (“Lyons”) is the Peoria County State’s Attorney and Frank Walter (“Walter”) is an investigator employed by that office.

In its capacity as a third party administrator, Mutual Medical also brokered Safe-co Company’s (“Safeco”) reinsurance products to the health plans that it serviced. This relationship was somewhat unique in the sense that it granted Jones the right to approve increases in the rates charged by Safeco for reinsurance to Jones’ clients. The ability to increase the rates was contingent upon Jones’ block of business, which at the time was comprised of approximately 63 employer health benefits plans, not exceeding certain levels of loss as a group.

In addition to commissions paid from Safeco to Jones and Mutual Medical, Mutual Medical was eligible to receive an annual “profit bonus” equal to one half of the profit earned by Safeco on Jones’ reinsurance clients after deductions were made for losses, reserves, conversion charges, pooling charges, and a target profit established by Safeco. Between 1995 and 1998, Mutual Medical’s profit bonuses were $260,361, $840,541, $601,730 and $523,624, respectively. The Company did not receive a profit bonus in 1999.

Mutual Medical, as a third party administrator, was responsible for processing and paying medical charges of employees and defendants who were covered by the health care plans it serviced. The Company was also responsible for making sure that its clients obtained reimbursement from the reinsurer, Safeco, whenever the claims incurred by an individual covered under a client’s health care plan exceeded the plan’s “stop-loss” or deductible point in a particular premium year. The profit bonuses received by Mutual Medical were largely dependent upon the total dollar amount in reinsurance claims that were paid by Safeco within a calender year.

The background for this lawsuit centers on three cases in which Mutual Medical served as the third party administrator for health care plans purchased from Safeco. These three cases will be referred to as the Wolfe, Boren, and Wilson cases.

The Wolfe Case

From July 1, 1992, to April 30, 1998, Mutual Medical served as the third party administrator for the self-funded benefit plan offered by PMP Fermentation Products, Inc. As part of its plan, PMP purchased individual excess loss insurance coverage from Safeco, under which Safeco would reimburse PMP for claim payments made in a reinsurance contract year (July 1st to June 30th) above the first $20,000 per person. On August 25, 1996, Mindy Wolfe, the wife of PMP employee Mitch Wolfe, prematurely gave birth to twin boys at OSF St. Francis Hospital (OSF) in Peoria. Drew and Derek Wolfe were hospitalized from August 25, 1996, through November 2,1996.

The OSF bills for the twins collectively totaled over $309,000. After receiving the bills in the fall of 1996, and early 1997, Jones and Mutual Medical claimed that the bills were excessive and, therefore, did not submit them to Safeco for reimbursement.

On June 27, 1997, Jones requested that Safeco extend the time period for PMP to submit claims for reinsurance on the Wolfe twins an additional 12 months, so that PMP would not be charged another set of deductibles. In his letter requesting the extension, Jones suggested that the poten *1071 tial reinsurance claim savings on the case was $200,000 or more. Safeco agreed to extend the time period, but only for an additional two months. Without notifying PMP officials 1 , in July of 1997 Mutual Medical hired a company, Preferred Payment Systems (PPS), to attempt to negotiate the bills, but OSF refused to consider that option and, the bills remained unpaid prior to the expiration of the extension period. 2

On October 29, 1997, Jones wrote a check from Mutual Medical’s account to OSF for partial payment of the Wolfe’s bill in the amount of $145,904 3 and an additional amount of $3,445.47 to the Wolfes to reimburse them for their expenses. The bill was not submitted to Safeco for reimbursement.

On March 27, 1998, PMP terminated Mutual Medical as its third party administrator for reasons unrelated to the Wolfe case. Shortly thereafter, PMP Human Resources Director Randy Niedermeier (“Niedermeier”) spoke with Jones, and it was revealed to PMP, for the first time, that the Wolfe matter was still unresolved by Mutual Medical.

On April 30, 1998, Niedermeier sent a letter to Jones demanding that Mutual Medical pay the balance of the Wolfe claim immediately. Shortly thereafter, the remaining balance of $163,400 was paid, and the charges were submitted to Safeco for reimbursement. Safeco reimbursed PMP $123,400 ($163,400 $40,000 deductible) on July 15,1998.

If the bills had been paid by Mutual Medical in the first eight months of 1997, Jones’ profit bonus would have been reduced by $154, 652. However, since Mutual Medical ultimately submitted $123,400 to Safeco for reimbursement in July, 1998, Jones’ 1998 profit bonus was decreased by only $61,700. As a result, the “net” increase to Mutual Medical’s profit bonus was $92,952. Because the Wolfe’s bills were not paid during the 1996-1997 policy year, PMP was forced to pay an additional $20,000 deductible for each twin. 4

The Wilson Case

Peoria County has a self-funded employee benefit plan to provide health insurance benefits to its employees and their dependents. Mutual Medical served at all relevant times as the third party administrator. Peoria County purchased excess loss insurance coverage from Safeco, which provided reimbursement for payments made in a reinsurance contract year above the first $150,000 per person.

On May 13, 1998, Tanisha Wilson, the wife of a Peoria County employee, prematurely gave birth to her daughter, Aalis, at OSF. Aalis remained at the hospital until she was discharged on July 23,1998. Payment was made on the first and third interim hospital bills, totaling approximately $118,000, in August and October, 1998. OSF records indicate that on July 2, 1998, the hospital sent Mutual Medical, by certified mail, the second interim bill in the amount of $73,228 for the care provided to *1072 Aalis.

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Bluebook (online)
309 F. Supp. 2d 1067, 33 Employee Benefits Cas. (BNA) 1369, 2004 U.S. Dist. LEXIS 4059, 2004 WL 504678, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mutual-medical-plans-inc-v-county-of-peoria-ilcd-2004.