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Osf Health Care System, An Illinois Not For Profit Corporation D/B/A v. Pekin Life Insurance Company

July 13, 2011

OSF HEALTH CARE SYSTEM, AN ILLINOIS NOT FOR PROFIT CORPORATION D/B/A
SAINT FRANCIS MEDICAL CENTER, PLAINTIFF,
v.
PEKIN LIFE INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: Joe Billy McDADE United States Senior District Judge

E-FILED Thursday, 14 July, 2011 09:45:30 AM Clerk, U.S. District Court, ILCD

ORDER & OPINION

Before the Court is Plaintiff's Motion for Leave to Amend the Request for Damages (Doc. 34); Plaintiff's Motion for Summary Judgment (Doc. 35); Defendant's Motion to Compel (Doc. 39); and Plaintiff's Motion for Leave to File Reply to Defendant's Response to Plaintiff's Motion for Summary Judgment (Doc. 42).*fn1

FACTUAL BACKGROUND AND PROCEDURAL HISTORY*fn2

Plaintiff provided medical goods and services to Howard Perkins from May 3-8, 2007. (Doc. 35 at 2). Plaintiff billed Defendant $95,628.60 for these services. (Doc. 35 at 2). Upon receipt of the bill, Defendant forwarded it to an outside contractor for review because the bill reflected "a lot of charges" for medical surgical supplies, as well as charges for nursing increments. (Doc. 35-13 at 21). The outside contractor manually entered the billing information into a computer program. (Doc. 35-1 at 15). The computer program then flagged certain charges as being inappropriately billed and/or coded. (Doc. 35-1 at 16-17). In reliance on the program's analysis, the contractor recommended that Defendant pay $69,435.30 to Plaintiff for the May 2007 medical treatment, and deny payment for certain medical goods and services totaling $21,118.35 on the ground that they were improperly billed.*fn3 (Doc. 35-13 at 27). Without performing any independent analysis of its own, Defendant accepted the contractor's recommendation, paying Plaintiff $69,435.30 and denying, as improperly billed, payment for goods and services billed in the amount of $21,118.35. (Doc. 35-13 at 26-7; Doc. 14-4 at 2). The reason cited for the denial of payment for such goods and services is that such goods and services should have been "bundled" into other costs; consequently, such charges are considered duplicative when billed separately. (Doc. 35-13 at 29; Doc. 35-2 at 11).

Plaintiff disagreed with Defendant's determination and appealed the decision with Defendant. In support of its appeal, Plaintiff claimed that such charges were usual and customary, that it bills all patients this way, and that such charges were not duplicative of other charges because Plaintiff minimizes its bundling of charges to save patients money. The Defendant, relying again on the advice of the very same outside contractor, refused to change its position. (Doc. 31 at 2).

The agreement that existed between the contractor and Defendant was that the contractor would get paid 30% of whatever charges were disputed. (Doc. 35-1 at 15). However, the contractor was paid nothing if it failed to identify charges for dispute. (Doc. 35-13 at 25). The Defendant cannot remember a time when it sent a bill to the contractor for review and the contractor did not identify charges for dispute. (Doc. 35-13 at 25). The Defendant's sole justification for refusing to pay Plaintiff for the goods and services billed in the amount of $21,118.35 is its reliance on the contractor's conclusion that such charges were improperly billed. (Doc. 35-14 at 11; 35-13 at 27).

On March 30, 2009, Plaintiff filed a Complaint alleging breach of insurance contract in the Circuit Court for Peoria County, Illinois. On April 29, 2009, Defendant timely removed this action, asserting federal question jurisdiction pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA").

LEGAL STANDARD

Summary judgment is proper "if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(a). The moving party bears the initial responsibility of informing the court of the basis for its motion and identifying the evidence it believes demonstrates the absence of a genuine issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323--24 (1986). If the moving party meets this burden, the nonmoving party cannot rest on conclusory pleadings but "must present sufficient evidence to show the existence of each element of its case on which it will bear the burden at trial." Serfecz v. Jewel Food Stores, 67 F.3d 591, 596 (7th Cir. 1995) (citing Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 585--86 (1986)). A mere scintilla of evidence is not sufficient to oppose a motion for summary judgment; nor is a metaphysical doubt as to the material facts. Robin v. Espo Eng. Corp., 200 F.3d 1081, 1088 (7th Cir. 2000) (citations omitted). Rather, the evidence must be such "that a reasonable jury could return a verdict for the nonmoving party." Pugh v. City of Attica, Ind., 259 F.3d 619, 625 (7th Cir. 2001) (quoting Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986)).

In considering a motion for summary judgment, the court must view the evidence in the light most favorable to the nonmoving party and draw all reasonable inferences in the nonmoving party's favor. Abdullahi v. City of Madison, 423 F.3d 763, 773 (7th Cir. 2005) (citing Anderson, 477 U.S. at 255). The court does not make credibility determinations or weigh conflicting evidence. Id.

ANALYSIS

The Court will first address Plaintiff's Motion for Leave to Amend the Request for Damages. (Doc. 34). On December 8, 2009, Plaintiff filed an Amended Complaint alleging its entitlement to $14,782.45 in damages -- an amount equal to 70% of the charges disputed by Defendant.*fn4 On July 8, 2010, Defendant's director of claims testified that Defendant would have been responsible for 100% of the disputed charges if they had been properly billed. (Doc. 35-14 at 5-6). On April 6, 2011, Plaintiff filed the instant motion seeking to amend the amount of damages being sought to $21,118.35. As its sole justification for seeking leave to upwardly amend the damages claim, Plaintiff cites Defendant's deposition testimony of July 8, 2010. The Defendant objects to Plaintiff's motion on the grounds that it is "untimely, prejudicial and futile."

In the absence of Defendant's consent to the amendment, F.R.C.P. 15(a)(2) requires Plaintiff to seek leave of the Court, which the Court is required to grant when justice so requires. However, the Court may deny the proposed amendment if the moving party has unduly delayed in filing the motion, if the opposing party would suffer undue prejudice, or if the pleading is ...


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