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Orellana v. Connecticut General Life Insurance Co.

United States District Court, W.D. Arkansas, Fayetteville Division

July 22, 2016




         Now pending before the Court are three ripe motions. First is a Motion for Summary Judgment (Doc. 19), which is accompanied by a Brief in Support (Doc. 20) and was filed by Defendant Connecticut General Life Insurance Company (“CIGNA”). CIGNA also filed a Supplementary Brief in Support (Doc. 28) and the Administrative Record (Doc. 27) relied upon by CIGNA in evaluating Plaintiff Erika Orellana’s claim for health care benefits. Ms. Orellana filed two Briefs in Opposition to the Motion, along with supporting exhibits (Docs. 21, 34), and CIGNA filed a Reply (Doc. 36). The Motion for Summary Judgment had previously been filed as a motion to dismiss; however, the parties had submitted a number of documents in support of their briefing on the motion that were not part of the public record, not part of the pleadings, and not embraced by the pleadings. Federal Rule of Civil Procedure 12(d) provides that if matters outside the pleadings are presented to the Court in conjunction with a motion brought under Rule 12(b), the motion must be treated as one for summary judgment under Rule 56. See Ashanti v. City of Golden Valley, 666 F.3d 1148, 1150-51 (8th Cir. 2012). Accordingly the Court converted the motion into one for summary judgment by Order entered on February 24, 2016. See Doc. 26. The Court then invited the parties to supplement the summary judgment record with further briefing and documents, and they did so.

         The second ripe motion is a Motion to Dismiss (Doc. 30) filed by Defendant Superior Industries, Inc. (“Superior”). Superior’s Motion and Brief in Support (Doc. 31) argue that since the case concerns only claims made pursuant to the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001, et seq., and since Superior granted discretionary authority to CIGNA to administer the entire claims process, Superior is not a proper party to be sued. Id. at p. 4. Ms. Orellana responds that it is far from clear that Superior is not the de facto administrator of the Plan because “the two entities [CIGNA and Superior] certainly seem to be working together.” (Doc. 35, p. 2).

         The third motion pending for resolution is Ms. Orellana’s Motion to Complete the Administrative Record (Doc. 32), which is accompanied by a Brief in Support (Doc. 33). In this Motion, Ms. Orellana maintains that the Summary Plan Description (“SPD”) from 2011 (Doc. 3-1)-which she concedes is not the correct SPD applicable to her ERISA claims in this matter-should nonetheless be included in the Administrative Record. She argues that when she requested Plan documents from Superior, she was given this wrong version of the SPD, and that she relied on this version when submitting her claim for health care benefits to CIGNA. CIGNA responds (Doc. 37) that the Administrative Record contains only those documents that CIGNA actually relied upon in evaluating Ms. Orellana’s claim. CIGNA maintains that since it did not rely on the 2011 version of the SPD, this document should not be added to the Administrative Record.

         For the reasons explained herein, the Motion for Summary Judgment (Doc. 19) is GRANTED, the Motion to Dismiss (Doc. 30) is GRANTED; and the Motion to Complete the Administrative Record (Doc. 32) is DENIED.

         I. BACKGROUND

         Ms. Orellana filed her Complaint in state court on November 24, 2015, and the case was removed to this Court by CIGNA and Superior on January 7, 2016. Ms. Orellana makes a claim for damages pursuant to ERISA for the recovery of health care benefits.[1]Her total claim of $8, 513.63 is broken down into three sets of bills owed to the following entities or individuals: (1) Benton Emergency Group/Francis M. Henderson, M.D. (“BEG”), for a bill totaling $991.00, (2) Northwest Medical Center (“NMC”), for a bill totaling $2, 146.63, and (3) Unruh Chiropractic and Wellness Center (“UCWC”), for a bill totaling $5, 376.00.

         The relevant Plan documents describe CIGNA as “[t]he office designated to consider the appeal of denied claims . . . .” (Doc. 27, p. 56). The Plan lists Superior as “the sponsor of the Plan” and as “Plan Administrator.” Id. However, according to the Plan, Superior, as Plan Administrator, “delegates to Cigna the discretionary authority to interpret and apply plan terms and to make factual determinations in connection with its review of claims under the plan.” Id. This discretionary authority includes “the determination of the eligibility of persons desiring to enroll in or claim benefits under the plan, the determination of whether a person is entitled to benefits under the plan, and the computation of any and all benefit payments, ” as well as the authority to “perform a full and fair review, as required by ERISA, of each claim denial which has been appealed by the claimant or his duly authorized representative.” Id.


         A. Motion for Summary Judgment

         Beginning with CIGNA’s Motion for Summary Judgment (Doc. 19), the law provides that “[t]he court shall grant summary judgment if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(a). The Court must view the facts in the light most favorable to the non-moving party, and give the non-moving party the benefit of any logical inferences that can be drawn from the facts. Canada v. Union Elec. Co., 135 F.3d 1211, 1212-13 (8th Cir. 1997). The moving party bears the burden of proving the absence of any material factual disputes. Fed.R.Civ.P. 56(c); Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586-87 (1986); Nat’l Bank of Commerce of El Dorado, Ark. v. Dow Chem. Co., 165 F.3d 602, 607 (8th Cir. 1999). If the moving party meets this burden, then the non-moving party must “come forward with ‘specific facts showing that there is a genuine issue for trial.’” Matsushita, 475 U.S. at 587 (quoting Fed.R.Civ.P. 56(c)). These facts must be “such that a reasonable jury could return a verdict for the nonmoving party.” Allison v. Flexway Trucking, Inc., 28 F.3d 64, 66 (8th Cir. 1994) (quoting Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986)).

         As previously discussed, Ms. Orellana’s Complaint for health care benefits under ERISA includes claims for bills from three medical providers. As to the first provider, BEG, Ms. Orellana admits there is no genuine, material dispute of fact that this bill “was correctly processed by the Defendant.” (Doc. 21, p. 1). Summary judgment on this claim will be granted to CIGNA, and the claim is dismissed with prejudice.

         As to the bill for NMC, Ms. Orellana agrees that CIGNA also resolved this claim in her favor, see Id. at p. 2, but complains that NMC “obviously disagrees with this conclusion and continues to bill Ms. Orellana, ” id. The Court finds that there is no genuine, material dispute of fact as to whether CIGNA properly processed this claim. Instead, Ms. Orellana’s grievance appears to be with NMC’s billing department. The undisputed evidence is that CIGNA informed Ms. Orellana in writing that she owed nothing on the bill to NMC. See Doc. 27, pp. 110, 112. It follows that summary judgment should be granted to CIGNA as to this claim, and it is also dismissed with prejudice.

         Turning finally to the UCWC bill, Ms. Orellana confirms that she submitted this claim to CIGNA in accordance with the procedure described in the 2011 SPD, which was allegedly provided to her by Superior. Superior apparently made a mistake in giving her the wrong Plan documents, as the 2013 SPD-and not the 2011 SPD-applied to her claims. Regardless of this error, Ms. Orellana complains that CIGNA never communicated with her about how it was processing the UCWC claim-nor did it inform her that it was ignoring the claim altogether because it did not consider it to have been properly submitted on the correct form. Ms. Orellana hired an attorney, who followed up with CIGNA in writing multiple times but never received a response about the status of this ...

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