University of Wisconsin Hospital & Clinics, Inc. v. Aetna Life Insurance

24 F. Supp. 3d 808, 2014 WL 2565284, 2014 U.S. Dist. LEXIS 77123
CourtDistrict Court, W.D. Wisconsin
DecidedJune 6, 2014
DocketNo. 13-cv-197-jdp
StatusPublished
Cited by2 cases

This text of 24 F. Supp. 3d 808 (University of Wisconsin Hospital & Clinics, Inc. v. Aetna Life Insurance) is published on Counsel Stack Legal Research, covering District Court, W.D. Wisconsin primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
University of Wisconsin Hospital & Clinics, Inc. v. Aetna Life Insurance, 24 F. Supp. 3d 808, 2014 WL 2565284, 2014 U.S. Dist. LEXIS 77123 (W.D. Wis. 2014).

Opinion

OPINION and ORDER

JAMES D. PETERSON, District Judge.

This is an action to recover payment for benefits provided under an employee health care plan governed by the Employee Retirement Income Security Act (ERISA). ERISA allows a participant in an ERISA-governed plan to bring a civil action to recover benefits due under the terms of his plan. 29 U.S.C. § 1132(a)(1)(B). The defendants in this case provided a health plan to the employees of Dik Drug Company, including James Vana. Defendant ADP TotalSource, Inc. is the plan administrator.1 Aetna Life Insurance Company provides the insurance policy that pays benefits under the plan and also decides what is covered.

This action is brought not by the participant himself, Vana, but by his health care provider, plaintiff University of Wisconsin Hospital and Clinics, Inc. (UW Hospital). Vana underwent a heart catheterization at the UW Hospital, a procedure that would likely have been covered under Vana’s plan if it had been properly’ “precertified” as medically necessary. But it was not pre-certified, an oversight by UW Hospital, but no fault of Vana’s. Aetna has refused to pay UW Hospital for the procedure. Vana assigned his rights under the plan to UW Hospital, and now UW Hospital seeks payment from the defendants.

Before the court are the parties’ cross-motions for summary judgment. Dkt. 3 and Dkt. 17. UW Hospital contends that despite its failure to precertify, the plan requires Aetna to pay for Vana’s procedure, although possibly at modestly reduced rate. Aetna and the other defendants disagree for two reasons. First, Aetna contends that UW Hospital does not have standing to bring an ERISA claim under 29 U.S.C. § 1132 because Vana himself will not be billed for the heart cathet-erization, and thus he has no rights to assign to UW Hospital. Second, Aetna contends that its denial of benefits was reasonable by the terms of the plan, which, for network providers such as UW Hospital, puts the burden to precertify and the consequences of failing to do so squarely on the provider. The court concludes that UW Hospital has standing under ERISA, and that Aetna’s denial of benefits was contrary to the terms of the plan. Accordingly, the court will grant UW Hospital’s motion for summary judgment and deny defendants’ motion.

UNDISPUTED FACTS

The court finds that the following facts are material and undisputed.

UW Hospital is a Wisconsin non-profit corporation that provides medical services and operates a hospital in Madison, Wisconsin. In June 2011, Vana’s primary care physician recommended that Vana have a cardiac catheterization. One of the nurses who worked with the primary care physician scheduled the procedure with UW Hospital. Doctors at UW Hospital performed the cardiac catheterization on Vana. The total cost of the UW Hospital care was $14,017.83, which included the catheterization itself and some additional services.

At the time of the procedure, Vana was a participant in an employee health and welfare plan sponsored by ADP Total-Source, Inc., with benefits underwritten [811]*811and insured by Aetna. UW Hospital is a network provider under the plan.2 Aetna initially paid $1,919.32 of the total cost of the care UW Hospital provided to Vana, and cited $213.27 as Vana’s responsibility. Aetna prepared an “Explanation of Benefits” document refusing to pay the balance because neither Vana nor UW Hospital sought precertification for the catheterization itself, as required for that procedure. UW Hospital repeatedly appealed Aetna’s denial of benefits, admitting its failure to precertify the catheterization, and asking Aetna to retroactively authorize Vana’s procedure. Aetna resolutely refused, on the grounds that the denial was “administrative” and that there were no “contract exceptions” to excuse UW Hospital’s failure to seek precertification. Aetna declined to undertake a “medical necessity” review to determine if Vana’s procedure would have been covered had UW Hospital sought precertification. Vana assigned his right to recover benefits to UW Hospital, which filed a complaint in Dane County Circuit Court seeking payment from the defendants. The defendants timely removed to this court alleging federal question jurisdiction because the dispute involves the enforcement of rights under an ERISA-governed plan.

Two documents describe the plan and govern its operation: the Benefit Plan and the insurance policy. The Benefit Plan describes the rights and obligations of Aet-na and plan participants, what the plan covers, and how benefits are paid.3 Dkt. 16-1, at 1-106 (In this Opinion, page citations to docket entries are to the file-stamped page numbers in the EOF headers). The second document, Aetna’s underlying insurance policy, contains the terms and conditions of coverage. Dkt. 16-2, at 72-102. The preface to the Benefit Plan explains that the Benefit Plan “is part' of the Group Insurance Policy between Aetna Life Insurance Company and the Policyholder.” Dkt. 16-1, at 4. The preface also states that “[a] person covered under this plan and their covered 'dependents are subject to all the conditions and provisions of the Group Insurance Policy.” Id.

The precertification process in the Benefit Plan is particularly important to this case. It is described in a section entitled “Understanding Precertification.” Id. at 14-16. This section of the Benefit Plan explains the purpose underlying the pre-certification requirement and describes the overall process:

Certain services, such as inpatient stays, certain tests, procedures and outpatient surgery require precertification by Aet-na. Precertification is a process that helps you and your physician determine whether the services being recommended are covered expenses under the plan. It also allows Aetna to help your provider coordinate your transition from an inpatient setting to an outpatient setting (called discharge planning), and to register you for specialized programs or case management when appropriate.
[812]*812You do not need to precertify services provided by a network provider. Network providers will be responsible for obtaining necessary precertification for you. Since precertification is the provider’s responsibility, there is no additional out-of-pocket cost to you as a result of a network provider’s failure to precertify services.
When you go to an out-of-network provider, it is your responsibility to obtain precertification from Aetna for any services or supplies on the precertification list below. If you do not precertify, your benefits may be reduced, or the plan may not pay any benefits.

Id. at 14 (original emphasis on defined terms omitted). Plan participants are not responsible for precertification of services from network providers; the network provider is responsible. Plan participants are, however, responsible for precertification of services from out-of-network providers.

The consequence to a participant of failing to secure precertification is not necessarily denial of coverage. Under the terms of the Benefit Plan, participants who fail to obtain precertification before undergoing treatment can still receive benefits if the policy would have covered such services had the participant sought precertifi-cation.

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Bluebook (online)
24 F. Supp. 3d 808, 2014 WL 2565284, 2014 U.S. Dist. LEXIS 77123, Counsel Stack Legal Research, https://law.counselstack.com/opinion/university-of-wisconsin-hospital-clinics-inc-v-aetna-life-insurance-wiwd-2014.