UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF ILLINOIS
April 7, 2011
ANNIE O. LEWIS, PLAINTIFF,
SHERWIN WILLIAMS SALARIED MEDICAL PLAN, DEFENDANT.
The opinion of the court was delivered by: J. Phil Gilbert District Judge
This matter comes before the Court on the bench trial held on February 23, 2011. Having heard and considered all the evidence presented by the parties and being fully advised of the premises, the Court hereby MAKES the following findings of fact and conclusions of law:
FINDINGS OF FACTS
1. Sherwin Williams Company is the Administrator of Defendant Sherwin Williams Salaried Medical Plan ("the Plan").
2. Aetna Life Insurance Company ("Aetna") is the Claims Administrator for the Plan.
3. Herbert Lewis ("Herbert") has been a participant in the Plan at all times relevant to this lawsuit.
4. Plaintiff Annie Lewis ("Annie") is the wife of Herbert. 5. Annie was enrolled as a beneficiary of the Plan and was eligible to receive covered benefits under the Plan at all times relevant to this lawsuit.
6. On December 17, 2006, Annie was injured in a horseback riding accident and thereafter received emergency care and subsequent medical care from multiple providers.
8. The providers submitted claims for payment relative to their medical services to Aetna. Annie claims Aetna failed to pay certain covered claims, specifically a $542.00 claim submitted by Salem-Flora Radiology and certain claims submitted by Bonutti Clinic.
9. Pursuant to the Plan, Annie and Herbert were required to share in the cost of Annie's medical care by paying copayments and/or coinsurance relative to claims submitted by Salem-Flora Radiology and Bonutti Clinic.
10. Pursuant to the Plan, certain provider discounts applied to claims submitted by Bonutti Clinic.
11. Aetna sent Explanation of Benefits ("EOB") letters to Herbert and Annie that explained Aetna's adjustments and payments pertaining to the medical services of Salem-Flora Radiology and Bonutti Clinic and identified the sums for which Herbert and Annie bore personal responsibility.
12. Annie and Herbert were personally responsible for $108.40 of the $542.00 Salem-Flora Radiology charge, leaving a balance of $433.60.
13. Aetna has certain records indicating that it paid Salem-Flora Radiology the $433.60 balance, but Salem-Flora Radiology has no record of receiving payment on its $542.00 claim as evidenced by the credible testimony of its bookkeeper.
14. With respect to the allegedly unpaid Bonutti Clinic charges, Aetna's records show that all but two charges, one in the amount of $129.00 and another in the amount of $89.00, were paid.
15. Applicable provider discounts reduced the $129.00 Bonutti Clinic charge to $103.20, and Annie and Herbert were personally responsible for $35.00 of that $103.20, leaving a balance of $68.20.
16. Applicable provider discounts reduced the $89.00 Bonutti Clinic charge to $71.20, and Annie and Herbert were personally responsible for $35.00 of that $71.20, leaving a balance of $36.20.
CONCLUSIONS OF LAW
1. The Plan is a welfare benefit plan as that term is defined in § 1002(1) of the Employee Retirement Income Security Act (29 U.S.C. § 1000 et.seq.).
2. As a welfare benefit plan under ERISA, the Plan is subject to ERISA's enforcement provisions found in §1132. (29 U.S.C. § 1132).
3. Pursuant to § 1132(a)(1)(B), as a beneficiary of the Plan, Annie sued the Plan to recover benefits due in relation to certain medical services provided by Salem-Flora Radiology and Bonutti Clinic.
4. Annie proved by a preponderance of the evidence that, despite its obligation to do so, the Plan did not pay $433.60 of a claim submitted by Salem-Flora Radiology and that it did not pay $68.20 and $36.20 relating to claims submitted by Bonutti Clinic.
6. The Court finds, pursuant to 29 U.S.C. 1132(a)(1)(B), in favor of Annie and against the Plan in the amount of $538.00.
7. The Court further finds that the Plan must pay Annie and Salem-Flora Radiology $433.60 to satisfy the unpaid claim of Salem-Flora Radiology and must pay Annie $104.40 to satisfy the unpaid claims of Bonutti Clinic. These amounts represent the extent of the Plan's liability to Annie and her medical providers.
As a final matter, the Court DISMISSES this matter with prejudice and DIRECTS the Clerk of Court to enter judgment accordingly.
IT IS SO ORDERED.
J. Phil Gilbert
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