Vencor, Inc. v. Standard Life & Accident Insurance

317 F.3d 629
CourtCourt of Appeals for the Sixth Circuit
DecidedJanuary 21, 2003
DocketNo. 01-5435
StatusPublished
Cited by1 cases

This text of 317 F.3d 629 (Vencor, Inc. v. Standard Life & Accident Insurance) 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
Vencor, Inc. v. Standard Life & Accident Insurance, 317 F.3d 629 (6th Cir. 2003).

Opinions

[631]*631ROSEN, District Judge, delivered the opinion of the court, in which GILMAN, Judge, joined. MOORE, Judge (pp. 643-646), delivered a separate dissenting opinion.

OPINION

ROSEN, District Judge.

I. INTRODUCTION

Plaintiff/Appellant, Vencor, Inc!, d/b/a Vencor Kentucky, Inc., d/b/a Vencor Hospital-Louisville and d/b/a Vencor Hospital-Chattanooga (“Vencor”), appeals two orders of the District Court for the Western District of Kentucky granting summary judgment to Defendant/Appellee Standard Life and Accident Insurance Company (“Standard Life”) in this breach of contract/promissory estoppel action. Specifically, Vencor seeks to recover the balances it claims it is owed by Standard Life for hospital services provided to two patients, Mac Weaks and Mildred Hollow. Both Mr. Weaks and Mrs. Hollow were covered by Medicare supplement (“Medigap”) insurance policies issued by Standard Life.

At issue in this appeal is the amount Standard Life was required to pay Vencor for Mr. Weaks’s and Mrs. Hollow’s medical care after their Medicare Part A benefits were exhausted. Vencor claims that, under the terms of the insurance policies, after Mr. Weaks’s and Mrs. Hollow’s Medicare Part A benefits were exhausted, Standard Life was required to pay Vencor its standard rates. Standard Life, on the other hand, contends that it is obligated to pay Vencor only the per diem rates allowed by Medicare, even after Medicare coverage has been exhausted.

The District Court agreed with Standard Life and, accordingly, entered summary judgment in its favor on both the breach of contract and promissory estop-pel claims. Vencor timely appealed. For the reasons set forth below, we affirm the judgment of the District Court.

II. FACTUAL BACKGROUND

A. MEDICARE PART A COVERAGE

The Medicare Act, 42 U.S.C. § 1395 et seq., provides health insurance for the aged and disabled. The Medicare program consists of two parts. Medicare Part A — the relevant program in this case-covers services provided to hospitalized patients.1 Medicare Part A covers expenses for ninety days for each “spell of illness.” See 42 U.S.C. § 1395d(a)(l). When a “spell of illness” is broken by a period of sixty days during which a patient is not hospitalized, a new period of ninety days commences. Id,.; see also 42 U.S.C. § 1395x(a). Medicare also allows for coverage of sixty additional life-time reserve days. See 42 C.F.R. § 409.61(a)(2). These reserve days are non-renewable. Id. The life-time reserve days can be used at any time; however, once they are used they are gone.

In addition to limiting the time of coverage, Part A also limits the types of services that are covered. The services that are covered include room and board, nursing services, drugs, supplies, and other diagnostic and therapeutic items or services furnished to inpatients. See 42 U.S.C. § 1395x(b); see also 42 C.F.R. § 412.23(c). Of these covered expenses, Medicare is further limited in that expenses will be covered only if they are reasonable and medically necessary. See 42 U.S.C. § 1395y(a)(l)(A).

Vencor, an operator of long-term hospital care facilities,2 accepts assignment of [632]*632Part A Medicare benefits from its patients. Medicare pays Vencor the lesser of the reasonable cost of its services or its customary charges, see 42 U.S.C. § 1395f(b)(l), pursuant to the Reasonable Cost Reimbursement System (“RCRS”). See 42 C.F.R. § 413. Under the RCRS, Medicare makes interim payments to Ven-cor subject to a year-end adjustment. 42 C.F.R. § 413.1(a)(1)(A). These interim payments are calculated on the basis of a per diem rate for each Medicare patient/beneficiary, which is derived by dividing the hospital’s “allowable net Medicare inpatient operating costs” in a base year by the number of Medicare beneficiaries in that year. See 42 C.F.R. § 413.40(a)(3)(D).

Medicare, however, does not cover the full per diem rate.3 During the first sixty days of hospitalization, Medicare covers all allowable costs, excluding a deductible. From the 61st to 90th days of hospitalization, Medicare pays the full amount of allowable costs, less a coinsurance amount for which the patient is responsible. During the sixty reserve days, Medicare pays the full amount of allowable costs, less a higher coinsurance amount, for which the patient is also responsible. 42 U.S.C. § 1395e(a)(l). After Part A benefits have expired, hospital patients can no longer rely on Medicare to cover their hospitalization expenses.

Because Medicare does not cover all of the health care costs of its beneficiaries, Medicare beneficiaries can obtain supplemental insurance to fill in the “gaps,” commonly known as “Medigap” insurance. Medigap insurance policies typically cover the initial deductible and coinsurance rates, as well as expenses after Part A benefits have been exhausted. Standard Life provides various forms of insurance in Kentucky and Tennessee, including Medi-gap insurance policies as described above.

B. PERTINENT PROVISIONS OF THE STANDARD LIFE MEDIGAP POLICIES AT ISSUE IN THIS CASE

Standard Life issued Mac Weaks a Me-digap insurance policy on January 25, 1991, and, on June 28, 1991, Standard Life issued an identical policy to Mildred Hollow. Both policies were issued in the. State of Tennessee. Both the Weaks and Hollow policies contain the following language and definition of “Medicare eligible expenses”:

‘Medicare Eligible Expense’ means health care expense of the kind covered by Medicare to the extent recognized as reasonable by Medicare.

[See Standard Life’s Weaks and Hollow policies, § 3, J.A. pp. 132,136],

Hospitalization coverage is set forth in the following policy provisions:

PART A BENEFIT. Standard Life will pay a benefit to supplement Part A of Medicare when you incur expenses as a result of injury or sickness. The benefit for each benefit period will be equal to the Medicare eligible expense you incur for the Part A hospital coinsurance amounts beginning with your 61st day of hospital confinement....

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
317 F.3d 629, Counsel Stack Legal Research, https://law.counselstack.com/opinion/vencor-inc-v-standard-life-accident-insurance-ca6-2003.