The opinion of the court was delivered by: Michael P. McCUSKEY Chief U.S. District Judge
Tuesday, 08 March, 2011 08:39:59 AM
Clerk, U.S. District Court, ILCD
This case is before the court for ruling on cross motions for summary judgment filed by Plaintiff, Rotech Healthcare Inc. (Rotech) and Defendant, Synthia Ann Huff (Huff).*fn1 Both parties are seeking judgment as a matter of law on Rotech's Complaint (#1) which was brought pursuant to section 502(a)(3) of the Employee Retirement Income Security Act of 1974, as amended (ERISA), 29 U.S.C. § 1132(a)(3). This court has carefully reviewed the arguments of the parties and the documents provided by the parties. Following this careful review, Huff's Motion for Summary Judgment (#9) is GRANTED and Rotech's Motion for Summary Judgment (#10) is DENIED.
Huff has experienced back and leg pain since in 1995. She was eventually diagnosed with L5-S1 spondylolisthesis and foraminal stenosis. In May 2004, Dr. Eric Potts of the Indianapolis Neurosurgical Group (ING) performed an L5-S1 interbody fusion on Huff, which alleviated the pain to some degree. Following the procedure, Huff saw Dr. Potts on June 21, 2004, at which time she had sacroiliac joint pain, low back pain and right posterior thigh pain, but had good motor function and her fusion was healing satisfactorily. Huff saw Dr. Potts on September 13, 2004, at which time she had some low back pain, had responded well to therapy and her fusion was still present. Huff was employed by Rotech and had group health insurance through Care First Blue Cross/Blue Shield (Care First).
On October 20, 2004, Huff was involved in an automobile accident and was injured. Her injuries were caused by Robert T. Hawkins, Jr., who disregarded a stop sign and struck Huff's vehicle with his vehicle. Following the collision, Huff was transported by ambulance to a hospital emergency room in Danville, Illinois. She was given medical care and treatment and was released to return home that evening. Subsequently, Huff experienced increased pain and returned to ING on November 17, December 27, and December 30, 2004. During these visits, Huff complained of left leg pain and back pain. Huff did not return to ING until May 25, 2005. On her May 25 visit, Huff had worsening right side low back pain. Her fusion was solid with good decompression of the spinal canal. Huff continued to receive treatment at ING. In June 2006, Dr. Potts determined that the conservative treatment provided to Huff was unsuccessful and he referred her to Dr. Derron Wilson, who was also a physician with ING.
On July 1, 2006, Huff no longer had health insurance through Care First. She became insured by United Healthcare Insurance Company (United Healthcare) under the Choice Plus Plan for Rotech (Plan). The Plan is an "employee welfare benefit plan" within the meaning of ERISA and is maintained for eligible employees of Rotech and their family members. Rotech is the Plan Administrator of the Plan and United Healthcare is the Claims Administrator of the Plan. After July 1, 2006, Huff continued to receive treatment at ING and had a spinal cord stimulator implanted by Dr. Wilson in September 2007. The Plan has paid $62,761.63 in medical benefits for Huff's treatment since July 1, 2006.
On September 21, 2006, Huff filed a lawsuit against Hawkins and his employers in the circuit court of Vermilion County, Illinois. Plaintiff sought monetary recovery for the injuries she sustained in the collision. On July 2, 2007, Huff signed, under oath, answers to interrogatories in the circuit court case. Huff stated that she received services from ING, with regard to her injuries from the collision, on August 9, 2006, August 31, 2006, September 22, 2006 and October 24, 2006. Huff also stated that she was unable to work because of her personal injuries on specified days from October 20, 2004 through January 25, 2007. Huff stated that she had received payment from her health insurance through United Healthcare for the injuries alleged in her complaint in the amount of $61,845.29.
The Plan permits the Plan Administrator and Claims Administrator to delegate their discretionary authority to other persons or entities who provide services in regard to the administration of the Plan. United Healthcare has delegated to Ingenix, Inc. (Ingenix) the responsibility and authority to seek and obtain reimbursement of the medical benefits that the Plan provided to Huff. In the circuit court action, United Healthcare, through Ingenix, claimed that it was entitled to a lien against any recovery obtained by Huff from any of the defendants in the amount of $62,761.63.
On August 18, 2008, the deposition of Dr. Potts was taken in the circuit court case. Dr. Potts testified that he first saw Huff in March 2004, at which time she complained of back pain and right leg pain. Dr. Potts testified that he performed the L5-S1 fusion on May 11, 2004. Dr. Potts stated that Huff still had some pain when he saw her on September 13, 2004. Dr. Potts testified that the accident in October 2004 caused a temporary exacerbation of Huff's underlying condition which manifested itself in her left leg. Dr. Potts testified that Huff was seen at ING on November 17, 2004, and on December 27, 2004, at which time Huff complained of left leg pain and back pain. Dr. Potts testified that, on December 30, 2004, Huff had left leg and back pain and received a steroid injection. Dr. Potts next saw Huff on May 25, 2005. Huff reported that she had slight worsening of the right side low back pain at that time. Dr. Potts saw Huff on August 31, September 22, and October 17, 2005. Dr. Potts testified that Huff described right side pain on these visits. Dr. Potts testified:
I think the pain that was present at that point was similar to the pain that she had preoperatively, you know, before the accident. The pain that -- whereas the left leg pain that was more temporally related to the auto accident and transient I think is easier to relate back to the auto accident of 2004.
Dr. Potts testified that he believed that the October 2005 right buttock pain was an expression of her underlying disease of the back that she had before the October 20, 2004, collision. Dr. Potts testified that he believed it was difficult to relate Huff's right-sided symptoms back to the accident. Dr. Potts testified that it was his opinion that "none of the medical care that was provided to [Huff] after January 1st of 2005 was causally related to the automobile collision she was involved in on October 20th, 2004." Dr. Potts testified that the January 13, 2006, procedure to remove instrumentation from Huff's L5-S1 fusion and the spinal cord stimulator implantation performed by Dr. Wilson were not causally related to the October 2004 automobile collision.
Dr. Wilson's deposition was also taken on August 18, 2008. Dr. Wilson testified that he began to see Huff in June 2006. Dr. Wilson testified that, based upon a review of Huff's chart, he thought the motor vehicle accident aggravated her conditions. Dr. Wilson was asked whether the implantation of the spinal cord stimulator, which was performed in September 2007, would have been necessary but for Huff's involvement in a motor vehicle collision. Dr. Wilson stated:
It's very difficult to -- it's very difficult to determine for patients that have spondylolisthesis and the fibrosis that she had, it's certainly a setup to have that type of problem. Whether it was the accident or another trauma, it certainly would have been possible. So it ...