Qualchoice, Inc. v. Williams

14 F. App'x 417
CourtCourt of Appeals for the Sixth Circuit
DecidedJune 22, 2001
DocketNo. 00-3485
StatusPublished
Cited by1 cases

This text of 14 F. App'x 417 (Qualchoice, Inc. v. Williams) 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
Qualchoice, Inc. v. Williams, 14 F. App'x 417 (6th Cir. 2001).

Opinion

PER CURIAM.

Plaintiff, QualChoice, Inc., appeals from the entry of summary judgment in favor of the defendant, Joseph Williams. Plaintiff, as fiduciary and administrator of the Lincoln Electric Employee Benefit Plan, brought suit for specific performance and restitution under the subrogation and reimbursement provisions of the Plan. Plaintiff contends that the district court erroneously concluded that the right to reimbursement for medical expenses paid on behalf of Williams was barred by the make-whole doctrine. After review of the record and the applicable authority, we find no error and affirm.

I.

Joseph Williams, a covered employee under the Plan, was injured in a motor vehicle accident on October 7, 1996. Plaintiff paid accident-related medical expenses for Williams totaling $75,187.93. Williams also incurred $9,149 in wage losses. Williams and his wife settled their claims against the party responsible for the accident for a sum of $115,000. Of that amount, $38,000 was allocated to the wife’s loss of consortium claim. Plaintiff concedes that the remaining $77,000 did not wholly compensate Williams for his injuries. Plaintiff nonetheless seeks reimbursement from the $77,000.

QualChoice filed this action in March 1999, seeking enforcement of the Plan’s subrogation and reimbursement provisions pursuant to 29 U.S.C. § 1132(a)(3)(B)(ii). The summary plan description sets forth the Plan’s rights under “Section Sixteen: Subrogation,” which states in pertinent part:

You agree to protect our lien rights if you are injured or become ill through [419]*419the act of a third party. If you are due money from such third party for the cost of such Covered Services, we will be subrogated for you for the purpose of collecting for those Covered Services. We will have the right to bring suit against such third party in your name to the extent permitted by applicable state law. If you receive payment, however designated, from a third party, you are obligated to reimburse us, less our pro rata share of the reasonable attorneys’ fees and costs you sustained in obtaining such recovery.

(Emphasis added.) With the consent of the parties, the case was transferred to the magistrate judge for final hearing and disposition pursuant to 28 U.S.C. § 636(c). On cross motions for summary judgment, the magistrate judge identified the “pivotal issue” to be “whether the federal common law make[-]whole doctrine applies to vitiate any obligation of the defendant to reimburse the Plan for medical expenses paid on his behalf.” Interpreting this court’s unpublished decision in Marshall v. Employers Health Insurance Co., Nos. 96-6063/96-6112, 1997 WL 809997 (6th Cir. Dec.30, 1997), the judge found the reimbursement language was ambiguous and, as a result, the make-whole rule applied to bar the Plan’s claim for reimbursement in this case. Judgment was entered in favor of defendant and plaintiff appealed.

II.

We review the district court’s grant of summary judgment de novo. See, e.g., Smith v. Ameritech, 129 F.3d 857, 863 (6th Cir.1997). Moreover, as the parties indicate, the interpretation of the Plan’s reimbursement provision is reviewed de novo. See Copeland Oaks v. Haupt, 209 F.3d 811, 813 (6th Cir.2000). This court, following the lead of the Ninth and Eleventh Circuits, adopted the make-whole rule of federal common law, which “requires that an insured be made whole before an insurer can enforce its right to subrogation under ERISA, unless there is a clear contractual provision to the contrary.” Copeland Oaks, 209 F.3d at 813. See also Cagle v. Bruner, 112 F.3d 1510 (11th Cir. 1997); Barnes v. Indep. Auto. Dealers of Cal. Health and Welfare Benefit Plan, 64 F.3d 1389 (9th Cir.1995).

Such a rule is consistent with the equitable principle that [an] insurer does not have a right of subrogation until the insured has been fully compensated, unless the agreement itself provides to the contrary. Also, the make-whole rule is merely a default rule. If a plan sets out the extent of the subrogation right or states that the participant’s right to be made whole is superceded by the plan’s subrogation right no silence or ambiguity exists.

Marshall, 1997 WL 809997, at *4. The panel in Marshall found the subrogation provision to be ambiguous and therefore subject to the make-whole rule. Because the separate reimbursement clause was un ambiguous, however, the beneficiary was required to reimburse the plan. The court explained that since subrogation and reimbursement are distinct rights, it was not necessary for them to be treated the same.

The magistrate judge concluded that Section Sixteen’s reimbursement language was ambiguous, reasoning that:

What distinguishes Marshall from this case is that the reimbursement language therein was in a separate paragraph from the subrogation language, each with headings which clearly identified them as “Subrogation” and “Reimbursement,” whereas the summary plan language at issue in this case is found within the provision labeled “Subrogation,” with no indication of any intent to separate the concepts. In this Court’s opinion this creates an ambiguity sufficient to warrant application of the [420]*420make[-]whole doctrine to the reimbursement obligation found within the subrogation clause in the present case. Consequently, the defendant would have no obligation to reimburse the Plan unless he had been made whole for the injuries he sustained.

QualChoice argues on appeal that the judge erred (1) by finding ambiguity based on the absence of a separate heading for the reimbursement provision and (2) by concluding that the make-whole rule applies to both subrogation and reimbursement rights. Our decision is controlled by two recently published decisions of this court concerning the make-whole default rule in the ERISA context.

In Copeland Oaks, the court drew upon Marshall and held that “in order for plan language to conclusively disavow the default rule, it must be specific and clear in establishing both a priority to the funds recovered and a right to any full or partial recovery.” Copeland Oaks, 209 F.3d at 813 (emphasis in original). In that case, the subrogation and reimbursement rights, which were set forth in a single provision, granted the plan priority over “any” funds paid by a third party. That was not sufficient to avoid the default rule because the language failed to specify that the rights to subrogation and refund had priority over even a partial recovery. As a result, the district court was found to have properly applied the make-whole rule.1

In Hiney Printing Co. v. Brantner,

Related

Boerger v. Davis, Unpublished Decision (7-22-2004)
2004 Ohio 3882 (Ohio Court of Appeals, 2004)

Cite This Page — Counsel Stack

Bluebook (online)
14 F. App'x 417, Counsel Stack Legal Research, https://law.counselstack.com/opinion/qualchoice-inc-v-williams-ca6-2001.