Provident Life & Accident Insurance Company v. United States

772 F. Supp. 1016, 1991 U.S. Dist. LEXIS 12586, 1991 WL 170976
CourtDistrict Court, E.D. Tennessee
DecidedJune 3, 1991
DocketNos. Civ-1-89-190, Civ.-1-89-316
StatusPublished

This text of 772 F. Supp. 1016 (Provident Life & Accident Insurance Company v. United States) is published on Counsel Stack Legal Research, covering District Court, E.D. Tennessee primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Provident Life & Accident Insurance Company v. United States, 772 F. Supp. 1016, 1991 U.S. Dist. LEXIS 12586, 1991 WL 170976 (E.D. Tenn. 1991).

Opinion

MEMORANDUM

EDGAR, District Judge.

This matter is before the Court upon the renewed motions of Provident Life and Accident Insurance Company (“Provident”) (Court File No. 172) and the Government for summary judgment (Court File No. 173) as to Provident’s defenses relating to damages, not liability.

I. Background

This lawsuit grows out of various amendments to the Medicare Act, 42 U.S.C. §§ 1101 et seq., which provide that Medicare is the secondary payor to group health plans under certain circumstances, including end-stage renal disease, the “working aged,” and the active disabled. (“MSP provisions”). See 42 U.S.C. §§ 1395y(b)(2), (3), (4) (1989). Under these provisions, “any entity responsible for payment” under these group health plans has the primary responsibility to pay for the insured’s health care costs over Medicare which would then pay on a secondary basis. These consolidated actions were filed in order to determine Provident’s responsibilities under the MSP provisions. In an earlier memorandum opinion and order, this Court ruled that Provident was liable for payment under the MSP provisions if it provided insurance under an employer group health plan as opposed to solely administrative services. 740 F.Supp. 492. (Court File Nos. 82, 83, as amended by Court File Nos. 84, 85 and 111, 112). In addition, the Court held that the Government is seeking recovery of Medicare primary payments under its independent statutory right of recovery as opposed to merely an action under subrogation. The issue now before the Court centers on which, if any, of the following defenses Provident may assert, as a matter of law, in the damages phase of this suit: (1) estoppel, (2) laches, (3) common law waiver, (4) statutory waiver, (5) mitigation of damages, and (6) set-off. The issue is not whether Provident is in fact entitled to these defenses.

II. Discussion

A motion for summary judgment shall be granted if, based on the record as a whole, there is no genuine issue of any material fact and the moving party is entitled to judgment as a matter of law. Fed.R.Civ.P. 56(c). The moving party “bears the burden of clearly and convincingly establishing the non-existence of any genuine issue of material fact, and the evidence as well as the inferences drawn therefrom must be read in the light most favorable to the party opposing the motion.” Kochins v. Linden-Alimak, Inc., 799 F.2d 1128, 1133 (6th Cir.1986).

However, “[o]nce the moving party presents sufficient evidence to support the motion under Rule 56(c), ... [t]he nonmoving party is not entitled to a trial merely on the basis of allegations; significant probative evidence must be presented to support the complaint.” Gregg v. Allen-Bradley Co., 801 F.2d 859, 861 (6th Cir.1986) (emphasis supplied). Only factual disputes whose resolution “might affect the outcome of the suit” are “material” and preclude the entry of summary judgment. 60 Ivy Street Corp. v. Alexander, 822 F.2d 1432, 1435 (6th Cir.1987). If, after reviewing the evidence, it appears that no such genuine issue of fact exists, the moving party is entitled to judgment as a matter of law. Fed.R.Civ.P. 56(c). See Celotex Corp. v. Catrett, 477 U.S. 317, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). In other words, if it becomes clear that no reasonable jury could find in favor of the plaintiff at the close of the proof, then dismissal under Rule 56 is in order. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248, 251-52, 106 S.Ct. 2505, 2511-12, 91 L.Ed.2d 202 (1986).

A. Estoppel

Provident argues that estoppel is available as a defense in this action because (1) Health Care Financing Administration (“HCFA”) officials were aware from the initial enactment of the MSP provisions [1019]*1019that its contractors made primary payments when Medicare did not have that responsibility, (2) HCFA officials encouraged this practice, and (3) as a result, Provident was injured since it may now, for various reasons attributable to the lapse of time, not be able to recover from other entities, i.e., employers, the amount of primary payments for which it may now be responsible. (Court File No. 172 at 13-15). To succeed in its assertion that the Government is now estopped from recovering mistaken primary payments, Provident must not only show that estoppel is a proper defense as a matter of law under these circumstances, but also that Provident reasonably and detrimentally relied upon the actions of HCFA officials and/or its agents.

In Heckler v. Community Health Services, 467 U.S. 51, 60, 104 S.Ct. 2218, 2224, 81 L.Ed.2d 42 (1984), the Supreme Court expressly left open the question of whether estoppel could be asserted against the Government, refusing to hold “that there are no cases in which the public interest in ensuring that the Government can enforce the law free from estoppel might be outweighed by the countervailing interest of citizens in some minimum standard of decency, honor, and reliability in their dealings with their Government.” (emphasis in original) (footnote omitted). Thus, a case may exist where estoppel could be asserted against the Government.

However, in order to succeed upon such a defense, Provident must establish not only the traditional elements of estoppel, but also some “affirmative misconduct” on the part of the Government and that the public’s interest is outweighed by the unfairness in imposing liability upon Provident. Watkins, v. United States Army, 875 F.2d 699, 707 (9th Cir.1989), cert. denied, — U.S.-, 111 S.Ct. 384, 112 L.Ed.2d 395 (1990) (Army affirmatively misrepresented in its official records throughout plaintiff’s fourteen-year military career that he was qualified for reenlistment, even though Army regulations provide that homosexuality constitutes a nonwaivable disqualification for reenlistment.). See Housing Authority v. Berg-land, 749 F.2d 1184, 1190 (6th Cir.1984) (No basis existed for estopping the Government from denying an application for federal funds because the preliminary site development had taken place in anticipation of approval of the application or because similar applications had previously been granted under an error of interpretation by governmental officials.). The Court concludes that this is not the exceptional case which the Supreme Court referred to in Heckler.

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Bluebook (online)
772 F. Supp. 1016, 1991 U.S. Dist. LEXIS 12586, 1991 WL 170976, Counsel Stack Legal Research, https://law.counselstack.com/opinion/provident-life-accident-insurance-company-v-united-states-tned-1991.