Semmler v. Metropolitan Life Insurance

172 F.R.D. 86, 1997 U.S. Dist. LEXIS 3479
CourtDistrict Court, S.D. New York
DecidedMarch 21, 1997
DocketNo. 94 Civil 5549 (SS)
StatusPublished
Cited by1 cases

This text of 172 F.R.D. 86 (Semmler v. Metropolitan Life Insurance) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Semmler v. Metropolitan Life Insurance, 172 F.R.D. 86, 1997 U.S. Dist. LEXIS 3479 (S.D.N.Y. 1997).

Opinion

OPINION AND ORDER

SOTOMAYOR, District Judge.

Plaintiffs move to reconsider and vacate the ruling of the Hon. Whitman Knapp granting summary judgment dismissing the claim of plaintiff Laura Melendez (the “Melendez judgment”). Plaintiffs further move for leave to amend the Complaint to add an additional plaintiff, Sharon Rocke, and to certify a class pursuant to Fed.R.Civ.P. 23. For the reasons to be discussed, plaintiffs’ motion to reconsider and vacate the Melendez judgment is DENIED; plaintiffs’ motion to add plaintiff Sharon Rocke is DENIED, and plaintiffs’ motion to certify the class is DENIED.

BACKGROUND

Plaintiffs are enrollees in various medical benefit plans funded and administered by defendant Metropolitan Life Insurance Company (“Met Life”). They have all undergone one of two forms of post-operative pain management: either patient controlled analgesia (“PCA”) or epidural narcotic administration (“ENA”). As explained by plaintiffs:

PCA involves the use of a pump, programmed and monitored under the supervision of anesthesiologists or other trained physicians, which permits a patient to [88]*88press a button to obtain pain medication intravenously as needed, within the limits set by the physician. [ENA] involves the insertion of a catheter into the epidural space near the spine through which pain medication can be infused continuously and/or intermittently.

(Pl. Class Cert. Mem. at 3). In this action, plaintiffs contest the decision made by defendant’s Claims Issues Committee (the “Committee”) to deny reimbursement for the expenses incurred in receiving these methods of post-operative pain management. Bringing causes of action based alternatively in the contract language of the plans or under ERISA, plaintiffs'insist that they are entitled to reimbursement for these “medically necessary” procedures performed by physicians and/or anesthesiologists.

Defendant contends that PCA and ENA are not separately reimbursable services. It maintains that post-operative pain management in the form of PCA and ENA is covered by the package surgical fee paid to the physician performing the surgery and to the surgical anesthesiologist. Reimbursing plaintiffs separately for them PCA and ENA treatments would amount to double-billing, in defendant’s view, because the physician’s package fee covers this treatment and because the physician historically has been responsible for ensuring post-operative pain treatment. Furthermore, defendant claims that PCA is not properly considered a service rendered by a “physician” because it is the patient him or herself who actually administers the pain killers — perhaps with the assistance of the nurses on duty.

With respect to plaintiffs motion to reconsider and vacate the judgment of the Hon. Whitman Knapp dismissing all claims of plaintiff Laura Melendez, defendant argues that the decision of the Committee to deny reimbursement for PCA was not arbitrary and capricious, but rather was based on substantial evidence after considering the relevant factors. The end product of the Committee’s decision was reasonable, defendant urges. Further, defendant claims that “[t]he evidence is clear and uncontradicted that the Committee’s decision was not influenced by any alleged conflict or financial interest” that would entitle plaintiff Melendez to de novo review of the Committee’s decision. (Def. Vacate Mem. at 21). For these reasons, and because plaintiff Melendez failed to exhaust her administrative remedies as required by the plan and by ERISA, defendant contends that Judge Knapp’s decision dismissing Ms. Melendez’s claim should be upheld.

In their motion to amend the complaint to add Sharon Rocke as an additional plaintiff and in them motion for class certification, plaintiffs maintain that all of the requirements for class certification have been met. They contend that the interests of justice will be served by the addition of Rocke as another ERISA plaintiff and that such addition “cannot conceivably prejudice defendant.” (Pl. Class Cert. Mem. at 2). Defendant, however, counters that class certification should be denied because: (1) individual issues of law and fact predominate over common issues; (2) the claims of the named plaintiffs are not typical of the claims of the class; (3) the representative parties will not fairly and adequately represent the class; (4) plaintiffs motion for class certification is untimely; (5) class action is not a superior method of resolving plaintiffs’ claims. Specifically with respect to the motion to amend the complaint to add plaintiff Rocke, defendant argues that this request should be denied “as untimely and prejudicial, and because Rocke’s claim is barred for failure to exhaust administrative remedies.” (Def. Class Cert. Mem. at 22).

DISCUSSION

I. Motion to Reconsider and Vacate the Dismissal of Melendez’s Claim

A. Procedural History

In his Septembex*, 1995 opinion, Judge Knapp granted defendant’s motion for summary judgment against plaintiff Melendez, writing:

Defendant has provided us with ample evidence of its own historical practice of paying for post-operative pain treatment through its surgical package and that such practice is not uncommon in the medical field. As well, defendant has a made a strong showing that surgeons are usually [89]*89qualified to perform all services related to PCA, the type of pain treatment which Melendez received. Thus we are unable to conclude that its decision to reject Melendez’ outstanding anesthesiologist’s bills was arbitrary and capricious, and we accordingly grant defendant summary judgment against Melendez.

Semmler v. Metropolitan Life Insurance, 1995 WL 559390, *11 (S.D.N.Y.1995). Because, inter alia, Judge Knapp did not consider the potential conflict of interest under which Metropolitan Life operated as a self-funded plan, and because of the Second Circuit’s intervening ruling in Sullivan v. LTV Aerospace & Defense Co., 82 F.3d 1251 (2d Cir.1996) which impacts that analysis, this Court permitted a reconsideration of Judge Knapp’s ruling.

B. Summai'y Judgment Standard

The standards for evaluating summary judgment motions are well established. Rule 56(e) provides that summary judgment is appropriate when:

the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law.

Fed.R.Civ.P. 56(c).

The burden is on the moving party to show that no genuine issue of material fact exists. See Gallo v. Prudential Residential Servs., Ltd. Partnership, 22 F.3d 1219, 1223 (2d Cir.1994) (citation omitted).

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172 F.R.D. 86, 1997 U.S. Dist. LEXIS 3479, Counsel Stack Legal Research, https://law.counselstack.com/opinion/semmler-v-metropolitan-life-insurance-nysd-1997.