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DeBartolo v. Health and Welfare Department of the Construction and General Laborers' District Council of Chicago and Vicinity

August 17, 2010

DR. HANSEL M. DEBARTOLO, PLAINTIFF,
v.
HEALTH AND WELFARE DEPARTMENT OF THE CONSTRUCTION AND GENERAL LABORERS' DISTRICT COUNCIL OF CHICAGO AND VICINITY, DEFENDANT.



The opinion of the court was delivered by: Hon. Maria Valdez United States Magistrate Judge

MEMORANDUM OPINION AND ORDER

Magistrate Judge Maria Valdez

This case presents claims under the Employee Retirement Income and Security Act of 1974, 29 U.S.C. § 1001, et. seq. ("ERISA"), and state law. The parties have consented to the jurisdiction of a United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). The defendant's Motion for Summary Judgment [Doc. No. 45] is now before the Court. For the following reasons, Plaintiff Hansel M. DeBArtolo's ERISA claims are dismissed with prejudice and the defendant's motion is granted with respect to the state law claims.

BACKGROUND FACTS*fn1

The defendant in this case is a multi-employer group health fund (the "Fund") covered by ERISA and maintained by a Board of Trustees composed of equal numbers of employee and employer trustees. Def.'s N.D. Ill. L.R. 56.1(a)(3) Statement of Facts ("Def.'s Facts") ¶ 1. The Fund pays benefits, including benefits for medical services, for eligible participants pursuant to a plan of benefits (the "Plan"). Id. ¶ 5.

Steven Vasicek was a member of the Fund and a participant in the Plan in October 1999. Id. ¶ 9. On October 10, 1999, he assigned his rights to certain medical benefits due from the Fund to the plaintiff, Dr. Hansel DeBartolo. Pl.'s N.D. Ill. L.R. 56.1(b)(3)(C) Statement of Additional Facts ("Pl.'s Facts") ¶ 10. He was scheduled to receive medical treatment from DeBartolo the next day. Id.

Before Vasicek's appointment on October 11, 1999, DeBartolo contacted a representative of the Fund by telephone. Id. ¶ 11. During the resulting conversation, DeBartolo asked if Vasicek was covered under the Plan, and informed the Fund's representative that Vasicek had assigned his rights to certain medical benefits due from the Fund to him. Id. ¶¶ 10, 11. In response, the Fund's representative verified that Vasicek was a Plan participant but did not inform DeBartolo that the Plan prohibited such assignments of medical benefits. Id. ¶ 11. The telephone conversation then ended, and DeBartolo provided medical treatment to Vasicek.

Def.'s Facts ¶ 10. He billed Vasicek $2,125.00 for the treatment provided and submitted a claim for payment to the Fund. Id.

The Fund received DeBartolo's claim on October 18, 1999, and reviewed the claim. Id. ¶¶ 10, 11. On February 1, 2000, a Fund representative contacted DeBartolo by telephone and requested that he reduce the amount of his claim because it exceeded the usual and customary charges allowable under the Plan for the types of medical services DeBartolo performed on Vasicek. Id. ¶ 11. DeBartolo refused to reduce his charge. Id. Two days later, on February 3, 2000, the Fund partially denied DeBartolo's claim. Id. ¶ 14. It directly paid DeBartolo $595.00 for the claim and denied the remaining $1,530.00 as excessive of the usual and customary charges for such services. The Fund notified DeBartolo and Vasicek of its determination by letter the same day. Id. ¶ 14.

DeBartolo says he requested an internal administrative review of the Fund's decision and a copy of the Plan the same day -- February 3, 2000 -- in a letter of his own. Pl.'s N.D. Ill. L.R. 56.1(b)(3)(B) Response to Def.'s Facts ("Pl.'s Resp.") ¶ 18. The Fund claims to never have received that letter; instead, it says DeBartolo's letter dated July 21, 2004 was the first communication it received from DeBartolo regarding his requests for administrative review of the Fund's decision and a copy of the Plan. Def.'s Facts ¶ 18. The Fund wrote to DeBartolo on August 9, 2004, and stated that his request for administrative review was untimely. Id. ¶ 19. It did not send him a copy of the Plan. Id. ¶ 19.

Over the next several years, DeBartolo repeated his request for administrative review of the Fund's decision. For example, DeBartolo sent a letter dated November 28, 2005 to the Fund that requested that the claim be processed according to the Plan.*fn2 Id. ¶ 21. The defendant answered that letter -- and reiterated its position that any request for administrative review of the Fund's decision was untimely -- on December 20, 2005. Id. Another letter was sent from DeBartolo to the Fund on June 22, 2006. Id. ¶ 22. The June 22, 2006 letter referenced a letter dated January 10, 2006, and stated that DeBartolo had first made a request for administrative review of the Fund's decision on February 3, 2000.*fn3 Id. The Fund claims it did not receive that January 10, 2006 letter and that June 22, 2006 was the first occasion it learned that DeBartolo believed he had made a request for administrative review on February 3, 2000. Id.

Correspondence between the parties continued throughout the remainder of 2006 and into 2007. On December 18, 2006, DeBartolo called the Fund to inquire about the status of his claim. Id. ¶ 23. In response, the Fund re-sent to DeBartolo letters it had previously mailed that explained that, as far as the Fund was concerned, DeBartolo's request for administrative review was untimely. Id. Two more letters requesting administrative review of the Fund's decision followed from DeBartolo on January 11, 2007 and February 12, 2007. Id. ¶¶ 24, 26. Those letters were answered (and denied as untimely) on January 24, 2007 and March 2, 2007. Id. ¶¶ 25, 27. DeBartolo then filed this suit on January 6, 2009 [Doc. No. 1]. He included with his complaint a copy of the assignment of medical benefits signed by Vasicek on October 10, 1999. Id. ¶ 28.

LEGAL STANDARD

Summary judgment is appropriate where "the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law." Fed. R. Civ. P. 56(c). The Court must draw all reasonable inferences in favor of the non-movant. Bennington v. Caterpillar Inc., 275 F.3d 654, 658 (7th Cir. 2001).

However, once the movant has carried its burden under Rule 56(c), "its opponent must do more than simply show that there is some metaphysical doubt as to the material facts." Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586 (1986). The party opposing summary judgment must offer admissible evidence in support of his version of events. McKenzie v. Ill. Dep't of Transp., 92 F.3d 473, 484 (7th Cir. 1996). "The mere existence of an alleged factual dispute is not sufficient to defeat a summary judgment motion. . . . The non-movant will successfully oppose summary judgment only when it presents 'definite, competent evidence to rebut the motion.'" Vukadinovich v. Bd. of Sch. Trs. of N. Newton Sch. Corp., 278 F.3d 693, 699 (7th Cir. 2002) (citations omitted).

DISCUSSION

This case involves two claims under ERISA and state law claims for estoppel and misrepresentation.*fn4 One ERISA claim is for benefits and stems from the Fund's decision to paritally deny the claim DeBartolo submitted after providing medical services to Vasicek in the fall of 1999 (the "Benefits Claim"). The Benefits Claim is asserted under 29 U.S.C. § 1132(a)(1)(B). The other ERISA claim is for statutory penalties and stems from the Fund's alleged failure to provide DeBartolo with copies of the Plan in response to his written requests (the "Penalties Claim"). The Penalties Claim is asserted under 11 U.S.C. § 1132(c)(1).

The Fund has attacked DeBartolo's claims on multiple fronts. It says that DeBartolo lacks standing to assert either the Benefits or the Penalties Claim and that both are barred by the applicable statutes of limitation. In addition, it says the Benefits Claim is improper because DeBartolo failed to exhaust the Plan's internal administrative remedies and that the Penalties Claim is deficient because it is not asserted against the Plan's administrator. Finally, the Fund argues that DeBartolo's estoppel and misrepresentation claims are preempted by ERISA. The ...


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