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Roche v. Travelers Property Casualty Insurance Co.

March 31, 2009


The opinion of the court was delivered by: J. Phil Gilbert District Judge


This matter comes before the Court on Defendant The Travelers Indemnity Company's Motion to Dismiss the Fourth Amended Complaint (Doc. 61). Plaintiff Kathleen Roche has responded and Defendant has replied. Defendant has also filed a Motion to Strike or Dismiss Class Allegations (Doc. 62) which is likewise fully briefed. For the following reasons, the Court GRANTS the Motion to Dismiss.


Plaintiff Kathleen Roche is a licenced healthcare provider who signed a provider agreement with First Health Group Corp. (First Health), thereby becoming a provider with the First Health PPO network. Defendant The Travelers Indemnity Company (TIC) signed a payor agreement with First Health, thereby becoming a payor with the First Health PPO network.

In 2003, Roche treated a patient, who was a covered claimant under a TIC worker's compensation insurance policy, at her offices in St. Clair County, Illinois. The claimant sustained injuries in a covered occurrence, and was entitled to worker's compensation coverage by TIC. Neither TIC nor First Health referred the patient to use Roche's services. They did nothing to steer or direct the patient in any way to Roche, nor did TIC make any attempt to verify Roche's status as a PPO provider before Roche provided her services to the patient.

Roche submitted a bill for her usual and customary charges to TIC. TIC then submitted the bill to First Health for review. Upon determining that Roche was a First Health PPO provider, TIC tendered payment to Roche at the PPO discounted rate for the services provided, along with an explanation of reimbursement form (EOR). The EOR represented that the claim had been reimbursed pursuant to the First Health Network. Roche contends that TIC was not entitled to take the PPO discount and is liable to her for the difference between her usual and customary rate and the PPO rate TIC paid. Roche contends that TIC was unjustly enriched by retaining for itself the difference between the rates. TIC counters that the Court should dismiss the complaint because Roche cannot sustain a claim of unjust enrichment against it.


For purposes of a motion to dismiss, the court must accept all factual allegations in the complaint as true and draw all reasonable inferences from those facts in favor of the plaintiff. Erickson v. Pardus, 127 S.Ct. 2197, 2200 (2007) (per curiam ) (quoting Bell Atlantic Corp. v. Twombly, 127 S.Ct. 1955, 1965 (2007)); Tricontinental Indus., Ltd. v. PricewaterhouseCoopers, LLP, 475 F.3d 824, 833 (7th Cir.2007). The federal system of notice pleading requires only that the plaintiff provide "a short and plain statement of the claim showing that the pleader is entitled to relief." Fed.R.Civ.P. 8(a)(2). In order to provide fair notice of the grounds for his claim, the plaintiff must allege sufficient facts "to raise a right to relief above the speculative level."

Pisciotta v. Old Nat'l Bancorp, 499 F.3d 629, 633 (7th Cir.2007)(quoting Twombly, 127 S.Ct. at 1965 (2007)) (internal quotations omitted). The complaint must offer "more than labels and conclusions, and a formulaic recitation of a cause of action's elements will not do." Twombly, 127 S.Ct. at 1965. Moreover, the Court is "not obliged to ignore any facts set forth in the complaint that undermine the plaintiff's claim." R.J.R. Services Inc. v. Aetna Casualty and Surety Co., 895 F.2d 279, 281 (7th Cir.1989). However, "when a complaint adequately states a claim, it may not be dismissed based on a district court's assessment that the plaintiff will fail to find evidentiary support for his allegations or prove his claim to the satisfaction of the factfinder." Twombly, 127 S.Ct. at 1969 n.8.

I. Unjust Enrichment

The parties agree that Illinois substantive law controls in this action.In order to state a claim of unjust enrichment in Illinois, a plaintiff must allege that the defendant unjustly retained a benefit to the plaintiff's detriment, and that the defendant's retention of the benefit violates fundamental principles of justice, equity and good conscience. B & B Land Acquisition, Inc. v. Mandell, 714 N.E.2d 58, 63 (Ill. App. Ct. 2000). "The premise of that doctrine is that a person who has been unjustly enriched at the expense of another is required to make restitution to the other." F.H. Prince & Co., Inc. v. Towers Financial Corp., 656 N.E. 2d 142, 151 (Ill. App. Ct. 1995) (internal quotes omitted).

Here, Roche has failed to allege that TIC retained a benefit to her detriment. She alleges that she submitted her bill to TIC, that TIC confirmed the bill was for a covered occurrence, and that TIC paid her an amount $531.81 less than the amount she billed. However, she has not alleged any facts from which the inference could be drawn that TIC was obligated to pay her bill at all, much less in full. Roche provided services to a patient, and she is entitled to reasonable compensation for those services. However, to the extent that a quasi-contract arose for the reasonable price of Roche's services, it arose between Roche and her patient. See, Victory Memorial Hosp. v. Rice, 493 N.E.2d 117, 119 (Ill. App. Ct. 1986). Roche has not alleged that she provided services to TIC. Roche has not alleged that she is entitled as a third-party beneficiary to bring an action on the insurance contract between her patient and TIC. Furthermore, to the extent that Roche is alleging that TIC must pay the reasonable costs of the treatment of her patient because the patient sustained a work-related injury, any such cause of action is precluded by the Worker's Compensation Act.*fn1

A. Illinois Workers's Compensation Act

"The Illinois Worker's Compensation Act [IWCA ] is designed to provide financial protection to workers for accidental injuries arising out of and in the course of employment. Accordingly, the Act imposes liability without fault upon the employer and, in return, prohibits common law suits by employees against the employer." Meerbrey v. Marshall Field and Co., Inc., 564 N.E.2d 1222, 1225 (Ill. 1990). Roche alleges that her patient was injured in an accident falling within the ambit of the IWCA and that his treatment was covered under a workers's compensation insurance policy. Therefore, her patient is entitled to compensation for his health care costs related to his injury. Roche appears to be ...

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