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Majestic Star Casino, LLC v. Trustmark Insurance Co.

November 17, 2009


The opinion of the court was delivered by: Robert W. Gettleman United States District Judge

Judge Robert W. Gettleman


Plaintiff Majestic Star Casino, LLC ("Majestic") filed a five-count amended complaint against defendants Trustmark Insurance Company ("Trustmark") and RMTS, LLC ("RMTS") alleging claims arising from a Trustmark policy for "stop loss" insurance for Majestic employee benefit plans. Trustmark subsequently filed a four-count counterclaim. The parties filed cross-motions for partial summary judgment, and on October 8, 2009, the court issued a memorandum opinion and order (the "October 8 Order") in which it denied summary judgment on Trustmark's claims that plaintiff, (1) failed to pay $285,251.36 within the benefit period designated in the stop loss policy, and (2) failed to pay different claims totaling $75,506.62 within 365 days from the last dates of service as required by the contracts.*fn1 Trustmark has moved for reconsideration of the October 8 Order. The motion is granted.

Generally, "[t]his Court's opinions are not intended as mere first drafts, subject to revision and reconsideration at a litigant's pleasure." Quaker Alloy Casting Co. V. Gulfco. Industries, Inc., 123 F.R.D. 282, 288 (N.D. Ill. 1998). Such motions are appropriate only to correct manifest errors of law or fact. Oto v. Metropolitan Life Insurance Co., 224 F.3d 601, 606 (7th Cir. 2002).*fn2

Central to the court's October 8 Order was the finding that a definition of the word "issue" was essential for ascertaining the timeliness of various payments Majestic made to cover employee health claims. Moreover, the court found that whether Trustmark waived these claims because it waited four years to raise the timeliness of payment as justification for not paying the claims raised a contested issue of fact. In the instant motion, Trustmark argues that the court's October 8 Order misinterpreted several key facts that, when properly considered, would counsel granting partial summary judgment in its favor on two separate groups of claims.

Late Paid Claims

Under the stop loss contracts, for a claim to be eligible for reimbursement Majestic must have "paid" the claim under its health plan within the designated benefit period. There is no dispute that claims under the 2004 contract were to be paid during the 2004 calender year, and claims under the 2005 contract were to be paid during the 2005 calender year. The parties also agree that the "paid date" is defined as the date a "check, draft or electronic fund transfer is [h]onored." The exception is when a payment is honored within 30 days of being "issued," in which case the "paid date" is the "issue date."

Trustmark argued in its original motion for partial summary judgment that Majestic paid claims totaling $285,251.36 outside of the designated benefit periods. Majestic countered, and the court agreed in its October 8 Order, that these late paid claims could not be resolved on summary judgment due to the lack of an agreed definition for the word "issue" under the contract, and because whether Trustmark had waived these arguments presented a contested issue of fact. Trustmark argues in the instant motion that notwithstanding the parties' dispute about the meaning of "issue date" -- which affects only $48,553.72 of claims paid in January of 2004 and 2005 -- there are undisputed facts supporting a finding of summary judgment in Trustmark's favor for the remainder of the claims totaling $236,697.64.

Trustmark draws the court's attention to an exhibit compiling checks listed on Majestic's bank records for January 1, 2004, through December 31, 2006. It argues that checks clearing more than 30 days after the end of the calendar year were issued on the date they were honored, rather than the date they were sent. Therefore, any checks that cleared Majestic's bank account after January 30 of the year following the end the applicable stop loss contract were "paid" on the date the checks were honored. Trustmark also contends that there are numerous checks that have never cleared Majestic's bank account, and claims filed based on these checks are ineligible for stop loss coverage.

Majestic agrees that the disputed definition of "issue date" is relevant only to the $48,553.72 of claims paid in the first 30 days of 2004 and 2005. It also does not dispute that claims totaling $236,697.64 were not paid within the benefit periods of the stop loss contracts. Instead, Majestic contends that Trustmark is estopped from denying these claims because it waived the payment requirements it now seeks to enforce. Specifically, Majestic argues that Trustmark waived the stop loss policies' payment requirements because it selectively enforced these requirements in an effort to save money. Majestic claims that Trustmark knew that Majestic's third party benefits administrator, Benefit Administrative Systems ("BAS"), was not paying underlying claims until it received advanced funding from Trustmark, and chose to remain silent in contravention of the advanced funding provisions of the stop loss contracts. Majestic thus contends that Trustmark delayed the processing of numerous stop loss claims, which resulted in long delays in BAS releasing Majestic's funds to health care providers.

In the October 8 Order, the court denied summary judgment on the late paid claims in part because it found that there was a question of fact whether Trustmark waived its argument because it waited four years to raise it as a justification for not paying the claims. On reconsideration, the court grants partial summary judgment in favor of Trustmark on this issue because Majestic has failed to establish that there are remaining genuine issues of material fact.

Majestic's first argument is that Trustmark is estopped from enforcing the payment requirement provisions in the contracts. Under Nevada law, which applies to the instant claim, the elements of estoppel are:

(1) the party to be estopped must be apprised of the true facts; (2) he must intend that his conduct shall be acted upon or must so act that the party asserting estoppel has the right to believe it was so intended; (3) the party asserting estoppel must be ignorant of the true state of facts; (4) he ...

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