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Boyle v. Liberty Mutual Insurance Co.

August 26, 2009

KATHLEEN BOYLE, AS EXECUTOR OF THE ESTATE OF KAREN M. CATLIN, DECEASED, AND SUCCESSOR TRUSTEE UNDER THE KAREN M. CATLIN TRUST DATED AUGUST 6, 1998, PLAINTIFF,
v.
LIBERTY MUTUAL INSURANCE COMPANY, LIBERTY MUTUAL EMPLOYEE BENEFIT PLAN, AND AETNA US HEALTHCARE, DEFENDANTS, AND ALDEN-POPLAR CREEK REHABILITATION AND HEALTH CARE CENTER, INC. RESPONDENT IN DISCOVERY.



The opinion of the court was delivered by: Hon. Harry D. Leinenweber

MEMORANDUM OPINION AND ORDER

Plaintiff Kathleen Boyle ("Plaintiff") and Defendants Liberty Mutual Insurance Company ("Liberty Mutual"), Liberty Mutual Medical Plan (the "Medical Plan"), and Aetna Life Insurance Company ("Aetna") (collectively, the "Defendants") have filed Cross-Motions for Summary Judgment with respect to Plaintiff's suit filed pursuant to the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132. Both parties seek summary judgment under Federal Rule of Civil Procedure 56(c), and, alternatively, Defendants seek judgment under Federal Rule of Civil Procedure 52(a). For the reasons set forth below, Plaintiff's Motion for Summary Judgment is denied, and Defendants' Motion for Summary Judgment is granted.

I. FACTUAL AND PROCEDURAL BACKGROUND

A. Parties

Plaintiff is the Executor of the Estate of Karen M. Catlin, deceased ("Catlin"), and Successor Trustee under the Karen M. Catlin Trust. Catlin was a former employee of the Wausau Insurance Company ("Wausau"), which was acquired by Liberty Mutual effective December 31, 1999. Defs.' Statement of Facts ("Defs.' SOF") ¶ 4; Pl.'s Statement of Facts ("Pl.'s SOF") ¶ 48. Former Wausau employees became eligible for coverage under the Liberty Mutual Medical Plan effective January 1, 2000. Aetna administers the Medical Plan for Liberty Mutual and is the Claims Administrator for the non-HMO plan option. Claims are initially determined by Aetna and, if denied, may be appealed to the Plan Administrator, Liberty Mutual. Defs.' SOF ¶ 15.

After Liberty Mutual and Wausau merged, Catlin enrolled in the Medical Plan's $1,000 Deductible Option, one of Liberty Mutual's self-insured, non-HMO options. Id. at ¶ 8. Prior to the merger, Catlin was enrolled in the Wausau medical plan, which was administered by Nationwide Insurance Company. Id. The parties dispute the date that Catlin's coverage under Liberty Mutual's Medical Plan became effective. Defendants assert that her coverage began January 1, 2000, and Plaintiff argues that her coverage began prior to that date. Based on the Court's ruling on the parties' motions and its reasoning, see infra, this dispute is immaterial. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). The record demonstrates, however, that Catlin was covered by Wausau's medical plan until December 31, 1999, and that her coverage under Liberty Mutual's Medical Plan began January 1, 2000. See Defs.' SOF ¶ 8; Post-Remand Admin. R. ("PRAR") RMD001880 (Dec. 22, 1999 Letter from Wausau); PRAR DEF 000004 (June 9, 2006 Letter from Aetna); PRAR RMD002441-62 (Aetna Case Summary).

At all times relevant to this matter, Catlin suffered from Amyotrophic Lateral Sclerosis ("ALS"). Defs.' SOF ¶ 5. In 1998, Catlin executed a Power of Attorney, delegating extensive authority to her attorney, including authority to apply for, receive, and exercise any right to elect benefits and to commence, pursue, or oppose legal proceedings on her behalf. PRAR DEF000017-20 ("Power of Attorney"). On December 16, 1999, Catlin was admitted as a resident of Alden-Poplar Creek Rehabilitation and Health Care Center, Inc. ("Alden"). Defs.' SOF ¶ 9; Pl.'s SOF ¶ 10. By a letter dated December 22, 1999, the Wausau benefits department confirmed a rate for skilled nursing facility services for Catlin at $269.20 per day. PRAR RMD001880 (Dec. 22, 1999 Letter from Wausau) (providing that "CERTIFICATION DOES NOT GUARANTEE BENEFITS. PAYMENT MAY BE SUBJECT TO ELIGIBILITY AND PLAN BENEFITS."). Except for a few days of hospitalization, Catlin remained at Alden until her death on July 25, 2004. Defs.' SOF ¶ 9; Pl.'s SOF ¶ 10.

B. The Medical Plan

The Liberty Mutual Medical Plan provides for certain "covered medical expenses," subject to other terms and provisions in the Medical Plan, including a maximum 100-day per year benefit for:

(4) [c]harges made by a skilled nursing facility for treatment rendered while confined:

(a) in lieu of a hospital confinement; or

(b) within 24 hours following hospital confinement and for the same or related cause(s) as such hospital confinement.

PRAR RMD000426-80 (Medical Plan), at B-24 & B-25. The Medical Plan defines "skilled nursing facility" as: a lawfully operating institution engaged mainly in providing treatment for people convalescing from injury or sickness. It must have:

(a) organized facilities for medical services; and

(b) 24-hour nursing service by Registered Nurses; and

(c) a capacity of six or more beds; and

(d) daily medical records for each patient; and

(e) a physician available at all times.

Id. at B-23 & B-24. The definition of skilled nursing facility specifically excludes "places for custodial care." Id. The Medical Plan also specifies that "charges for custodial care" do not qualify as a "covered medical expense." Id. at B-33. The Medical Plan defines "custodial care" as: a level of routine maintenance or supportive care, whether provided in the home or in an institution or other facility, which need not be provided by skilled professional medical ...


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