Trident Regional Health Sys. v. Polin

948 F. Supp. 509, 1996 U.S. Dist. LEXIS 17943, 1996 WL 697737
CourtDistrict Court, D. South Carolina
DecidedOctober 17, 1996
DocketC/A 2:96-596-21
StatusPublished
Cited by5 cases

This text of 948 F. Supp. 509 (Trident Regional Health Sys. v. Polin) is published on Counsel Stack Legal Research, covering District Court, D. South Carolina primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Trident Regional Health Sys. v. Polin, 948 F. Supp. 509, 1996 U.S. Dist. LEXIS 17943, 1996 WL 697737 (D.S.C. 1996).

Opinion

ORDER

TRAXLER, District Judge.

Plaintiff Trident Regional Health System (“Trident”) instituted an assumpsit action in state court against Defendant — Third-Party Plaintiff Candace Polin (“Polin”), alleging that Polin owed $82,638.45 for medical services rendered, plus interest, attorney’s fees, and costs. Polin admitted that she incurred the expenses Trident claimed, but denied liability, and filed a third-party action against Third-Party Defendant Life Cycle Engineering (“Life Cycle”), asserting that Life Cycle was liable for the medical services owed to Trident. Pursuant to 28 U.S.C.A. § 1441 (West 1994) and 29 U.S.C.A. § 1132(e)(1) (West Supp.1996), Life Cycle removed the actions to federal district court and subsequently moved for summary judgment pursuant to Federal Rule of Civil Procedure 56(e). According to Life Cycle, Polin failed to comply with the terms of her employee health benefits plan, a plan governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C.A. §§ 1001-1461 (West 1985 & Supp.1996) (ERISA), so Life Cycle is riot required to pay Polin’s medical experises until Polin recognizes Life Cycle's subrogation rights. Specifically, Life Cycle asserts that because Polin refused to comply with the subrogation terms of the Plan, it need not make any payments respecting her medical expenses until she has fulfilled her obligations under the Plan; thus, Life Cycle does not deny liability for Polin’s medical expenses, but argues that it need not disburse funds until Polin signs the subrogation agreement. Polin opposes Life Cycle’s motion for summary judgment, but does not assert that any material facts are disputed. Rather, Polin contends that Life Cycle cannot assert a breach of the subrogation terms of the Plan because Life Cycle has not paid any of her medical expenses. Concluding that Life Cycle need not yet reimburse Polin for her medical expenses and may enforce its subrogation rights prior to complete satisfaction of her medical expenses, the court grants Life Cycle’s motion for summary judgment. 1

I.

The material facts are neither disputed nor complicated. At all material times, Polin was an employee of Life Cycle, and in this capacity, participated as a “covered person” in an ERISA welfare plan (“Plan”) that provides health insurance coverage. Life Cycle was both Plan fiduciary and administrator. In promulgating and implementing the Plan, Life Cycle reserved to itself “full discretionary authority to interpret and apply all Plan provisions, including, but not limited to, all issues concerning eligibility for and determination of benefits.” (Plan at 1). Thus, Life Cycle is the interpreter of the Plan’s provisions.

While traveling in an automobile driven by Kari Antley (“Antley”), Polin was injured when Antley collided with another vehicle. Consequently, Polin engaged Florida attorney Scott Seifert (“Seifert”) to institute suit against Antley and Antley’s insurance provider, Nationwide Insurance Company (“Nationwide”). Polin settled her suit with Antley and Nationwide: Polin released Antley from liability to herself and Life Cycle for $25,000.

Conspicuously, Polin did not notify Life Cycle of her suit against Antley and Nationwide, nor did she obtain permission from Life *512 Cycle to settle her suit, obligations imposed on her by the Plan. Specifically, the Plan provides in pertinent part:

The Covered Person shall notify the Plan of the existence of any claim that the covered person may have against any negligent person or organization---- The Covered Person agrees to not settle any claim that they [sic] may have, or enter into any compromise, or accept any settlement of any claim for which the Plan has a subrogation right, or a right to recover, without prior approval by the Plan.

(Id. at 62). Thus, Polin’s instituting suit against Antley and Nationwide and settling that suit without prior approval from Life Cycle breached the express provisions of the Plan.

Having sued and settled in violation of the Plan, Polin then sought benefits under the Plan from Life Cycle because the $25,000 was insufficient to satisfy all of her medical expenses. Despite seeking benefits, Polin refused to sign an instrument that protected the Plan’s subrogation rights — hardly surprising since she settled her suit with Antley and Nationwide without permission from the Plan administrators, thereby prejudicing the Plan’s rights. Similarly, Polin refused to execute an instrument requiring her to apply the $25,000 settlement to repay the Plan for any expenses the Plan would incur on her behalf. Polin refused to sign these instruments even though the Plan affirmatively imposed this duty:

It is further agreed that the Covered Person will sign a written agreement to repay the Plan in full out of any monies that the covered person receives from a negligent person or organization. If the Covered Person fails to sign such an agreement, the Plan reserves the right to withhold payment of the Covered Person’s claims, which relate to the negligence of another person or organization, until such time as the Covered Person signs the agreement to repay.

(Id.). Had Polin complied with the terms of the Plan, Life Cycle would have paid the benefits, and in the event Polin was aggrieved, she could have appealed any denial of benefits and sought administrative remedies as provided for in the Plan. (Id. at 70-71).

Because of Polin’s breaches and recalcitrance, Life Cycle refused to pay any benefits in accordance with its interpretation of the Plan. In refusing to disburse funds to Polin, Life Cycle relies on the subrogation provision in the Plan, which provides in pertinent part:

In the event that this Plan pays benefits for the expenses of a Covered Person, and those expenses were due to the negligence of a third party, the Plan shall be subrogated to all of the Covered Person’s rights of recovery of those benefits against any person or organization. This means that if the Covered Person receives any monies from a negligent Person or organization, the Plan is entitled to recover its expenses from the negligent person or organization. The Plan is entitled to pro-tanto subrogation____ The Covered person shall cooperate with the Plan and do whatever is necessary to secure the Plan’s subrogation, or right of recovery rights. This includes providing any information requested by the Plan.

(Id.). According to Life Cycle, Polin materially breached the subrogation provisions of the Plan and is thus precluded from recovering any benefits under the Plan, even though Life Cycle has not paid any benefits under the Plan.

II.

Federal Rule of Civil Procedure 56(c) requires that the district court enter judgment against a party who, “after adequate time for ... discovery[,] fails to make a showing sufficient to establish the existence of an element essential to that party’s ease, and on which that party will bear the burden of proof at trial.” Celotex Corp. v. Catrett,

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Bluebook (online)
948 F. Supp. 509, 1996 U.S. Dist. LEXIS 17943, 1996 WL 697737, Counsel Stack Legal Research, https://law.counselstack.com/opinion/trident-regional-health-sys-v-polin-scd-1996.