The opinion of the court was delivered by: J. Phil Gilbert United States District Court Judge
This matter comes before the Court on defendant Protestant Memorial Medical Center's ("Memorial") motion for summary judgment (Doc. 43). Plaintiff Cynthia Whitcher has responded to the motion (Doc. 51), and Memorial has replied to that response (Doc. 52).
I. Standard for Summary Judgment
Summary judgment is appropriate where "the pleadings, the discovery and disclosed materials on file, and any affidavits show that there is no genuine issue as to any material fact and that the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(c); see Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986); Spath v. Hayes Wheels Int'l-Ind., Inc., 211 F.3d 392, 396 (7th Cir. 2000). The reviewing court must construe the evidence in the light most favorable to the nonmoving party and draw all reasonable inferences in favor of that party. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 255 (1986); Chelios v. Heavener, 520 F.3d 678, 685 (7th Cir. 2008); Spath, 211 F.3d at 396.Where the moving party fails to meet its strict burden of proof, a court cannot enter summary judgment for the moving party even if the opposing party fails to present relevant evidence in response to the motion. Cooper v. Lane, 969 F.2d 368, 371 (7th Cir. 1992).
In responding to a summary judgment motion, the nonmoving party may not simply rest upon the allegations contained in the pleadings but must present specific facts to show that a genuine issue of material fact exists. Fed. R. Civ. P. 56(e)(2); Celotex, 477 U.S. at 322-26; Johnson v. City of Fort Wayne, 91 F.3d 922, 931 (7th Cir. 1996). A genuine issue of material fact is not demonstrated by the mere existence of "some alleged factual dispute between the parties," Anderson, 477 U.S. at 247, or by "some metaphysical doubt as to the material facts," Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586 (1986); Michas v. Health Cost Controls of Ill., Inc., 209 F.3d 687, 692 (7th Cir. 2000). Rather, a genuine issue of material fact exists only if "a fair-minded jury could return a verdict for the [nonmoving party] on the evidence presented." Anderson, 477 U.S. at 252; accord Michas, 209 F.3d at 692.
Viewing the evidence and drawing all reasonable inferences in Whitcher's favor, the Court finds the following facts for the purposes of this motion.
At all relevant times, plaintiff Whitcher was employed by defendant Memorial and was covered by the Protestant Memorial Medical Center, Inc. Employee Healthcare Plan ("Plan"), an employee welfare plan governed by the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq. The Plan names Memorial as its plan administrator. See Plan § 1.66. Memorial selected Westport Benefits, followed by Meritain Health, Inc., as its claims administrator. See Plan § 1.14.
Whitcher had suffered from morbid obesity and related disorders since at least March 1995. She had tried various methods of weight reduction, including several requiring prescription drugs, and her doctor, Dr. Kirk, supervised and monitored her efforts. When none of her efforts produced the magnitude of weight loss desired, in January 2005 Dr. Kirk recommended she have bariatric surgery ("the Procedure").
Whitcher sought pre-certification under the Plan. On March 10, 2005, the claims administrator declined to approve the Procedure. It stated that the Procedure is not covered by the Plan because it must be rendered by a Memorial or Healthlink (the preferred provider organization ("PPO") the Plan required its participants to use) provider and because no diet history or psychological consultation was submitted with the pre-certification request.
In response to that denial, on May 10, 2005, Dr. Kirk submitted additional information regarding the history of Whitcher's attempts to lose weight, including the fact that she was under his care during those efforts. Dr. Kirk's memo also opined that Whitcher's psychiatric status was stable for the Procedure. Three days later, on May 13, 2005, the claims administrator again refused to approve the Procedure, finding that it was not medically necessary because the claims administrator had no medical records to support that Whitcher's weight loss efforts had been monitored by a physician. The May 13, 2005, letter encouraged her to provide such documentation or, if none existed, to participate in a medically supervised, structured weight loss program for six months, then submit the requested documentation for reconsideration of the medical necessity determination. Whitcher did not submit any additional materials and, on May 17, 2005, underwent the Procedure despite the lack of pre-certification. As a result, she incurred medical bills of approximately $27,725, which she paid in full. Her charges did not reflect the discount negotiated for her with PPO providers providing services under the Plan.
In a letter dated November 1, 2005, Whitcher submitted a claim to Memorial for reimbursement of her medical expenses. On December 22, 2005, Memorial forwarded Whitcher a December 21, 2005, letter from the claims administrator indicating that Whitcher's claim should not be paid. That determination was based on the fact that Whitcher had not submitted her claim first to HealthLink for "repricing" (that is, application of the negotiated discount) and that Whitcher did not submit the claim in the standard billing format that included a diagnosis code. The claims administrator indicated that if Whitcher submitted her claim to HealthLink first and in the appropriate format, it would reconsider her claim. The claims administrator also noted that Whitcher could submit additional information relevant to her claim and noted Whitcher's right to appeal the denial decision within 60 days of receiving notice of it.
The Plan's internal appeals process by which a participant can appeal an adverse claim decision is set forth at § 9.6(B):
A claimant whose claim is denied, in whole or in part, may submit a written request to the Claims Administrator for a review of the determination within (60) days after receipt by the claimant of written notification of the denial of the claim. . . . Such claimant, or his duly authorized representative, shall be given the opportunity to review pertinent documents and submit issues and comments in writing. The Claims Administrator may hold a hearing or conduct an independent investigation regarding the merits of the denied claim. A decision on review shall be made within sixty (60) days after the receipt of the ...