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TORMEY v. GENERAL AMERICAN LIFE INS. CO.

July 30, 1997

JOHN TORMEY, Plaintiff,
v.
GENERAL AMERICAN LIFE INSURANCE COMPANY, Defendant.



The opinion of the court was delivered by: CASTILLO

 In this action plaintiff John Tormey charges that defendant General American Life Insurance Company wrongfully denied him medical coverage due to a preexisting condition clause in his insurance plan. Tormey is seeking a declaratory judgment to the effect that General American is liable for his medical expenses (count I), and asserting claims of estoppel (count II), and bad faith (count III). *fn1" General American moves for summary judgment on the grounds that ERISA preempts Tormey's state law claims and that Tormey received all the benefits he is entitled to receive under the insurance plan. General American further maintains that summary judgment is appropriate because there is no legal or factual support for an ERISA estoppel claim. For the following reasons, General American's motion for summary judgment is granted.

 RELEVANT FACTS

 The following facts are taken from the statements of fact submitted by the parties pursuant to Local General Rule 12, and the responses thereto as well as other pleadings and exhibits submitted to the court in connection with the pending motion. John Tormey was a maintenance man at Tinley Court Retirement Home in Tinley Park, Illinois. Tinley Court provided medical coverage to its employees through Principal Mutual Life Insurance Company (hereafter known as the Principal-Tinley plan). (Rule 12(M) P 4). When Tormey stopped working at Tinley Court in January 1995, he elected to extended his medical coverage under the Comprehensive Omnibus Budget Reconciliation Act of 1986 (COBRA), 29 U.S.C. ยง 1161, et seq. (Id. P 5). Tormey received COBRA benefits until June 30, 1995. (Id. P 8).

 On March 15, 1995, Tormey began working as a maintenance man at M. Meyers Properties (hereafter known as Meyers). Meyers provided group medical coverage through Principal Mutual Life Insurance Company (hereafter known as the Principal-Meyers plan). (Id. P 6). The Principal-Meyers Plan contained a 90-day probationary period and Tormey's coverage began on June 12, 1995. (Id. P 7). Tormey terminated his COBRA benefits shortly thereafter. (Id. P 8). In August of 1995, however, Tormey's supervisor, Christina Epple, informed him that effective September 1, 1995, Meyers would have a new group plan issued by General American Life Insurance Company. The General American plan and the Principal-Meyers plan were paid for by Meyers at no cost to its employees. (Id. P 9).

  Catherine Boxall, an accounts representative from General American, visited Meyers in August 1995 to familiarize Tormey and four of his colleagues with General American's medical coverage plan. (Id. P 17). Boxall defined the plan's preexisting condition clause for the group and addressed any concerns that the employees had regarding the provision. (Id. P 18). Tormey explained that he had heart attacks in November 1993 and May 1995 and asked Boxall if that would affect his coverage. *fn2" Boxall asked Tormey if he was under a doctor's care and Tormey replied that he was not, although the parties disagree about the precise wording of Boxall's question. Boxall claims she asked Tormey if he had been under a doctor's care within the past three months. (Id. P 18 n.3). Tormey's deposition contains conflicting statements. At first, Tormey maintained Boxall asked if he was previously under a doctor's care. However, he later states that Boxall asked if he was presently under a doctor's care (emphasis added). (Pl.'s Dep. at 55-56, 60-61). In any event, Tormey claims that Boxall told him that his previous heart attacks were not preexisting conditions and that he would be covered under the plan. Therefore, Tormey did not investigate any alternative medical coverage or seek reinstatement of his COBRA benefits. (Rule 12(M) P 20). Tormey's coverage under General American began on September 1, 1995. (Id. P 9).

 John Tormey suffered his third heart attack on September 23, 1995 and three days later he had heart bypass surgery. (Id. P 10). As a result, Tormey incurred numerous medical expenses, totaling $ 66,594.70. ( Id.). In the ten months following Tormey's heart attack, General American sent Tormey sixteen invoices indicating that it had paid for various medical services ranging from $ 12 to $ 380. *fn3" (Pl.'s Mem. in Resp. to Def.'s Mot. for Summ. J. at 10). The invoices submitted by General American were labeled; a majority of them were for X-rays, laboratory tests with cardiovascular physicians, and appointments with Tormey's cardiologist, Dr. Eric Teplitz. (Id.). On October 15, 1996, General American responded to an invoice from Christ Hospital for fees totaling $ 28,440.75 by stating, "This claim has been sent for pricing." (Id. at 11).

 General American investigated Tormey's claim and discovered his two previous heart attacks. (Rule 12(M) P 14). Following each of the first two heart attacks, Tormey underwent an angioplasty. (Id.). After his second heart attack, Tormey's treating cardiologist, Dr. Eric Teplitz, prescribed four heart medications (Coumadin, Norvasc, Zestril, and Lopid), which Tormey took on a daily basis between May 1995 and September 23, 1995. (Id. P 14). In addition, Tormey had office visits with Dr. Teplitz for his heart condition on May 12, 1995, June 7, 1995, and June 26, 1995. *fn4" (Id. P 14). Based on his medical history and the provisions in the medical coverage plan, General American concluded that Tormey was not eligible for benefits because his heart attack was a preexisting condition. (Id. P 15).

 General American's preexisting condition clause states:

 
You or your covered dependent has a "preexisting" condition if you or your covered dependent;
 
1. Has consulted a doctor;
 
2. Has taken prescribed medicine;
 
3. Is receiving or has received medical care for that condition in the three months before your coverage with this plan became effective.
 
Benefits will not be payable until one of the following occurs;
 
2. You or your covered dependent has been insured under this plan for twelve months in a row.

 (Id. P 11; see also General American plan, Def.'s Ex. 3 at 43). However, the applicable definition of a preexisting condition is derived from the Principal-Meyers plan because the General American plan also contains the following plan replacement provision:

 
The plan will pay benefits for the preexisting conditions (otherwise excluded under the Preexisting Condition Limitations provision), but only for the lesser of:
 
(a) the benefits provided under this plan without application of the preexisting ...

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