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Centro Medico Panamericano, Ltd. v. Laborers' Welfare Fund

Court of Appeals of Illinois, First District, Third Division

May 13, 2015

CENTRO MEDICO PANAMERICANO, LTD., an Illinois corporation, s/b/a Fullerton Kimball Medical and Surgical Center, Plaintiff-Appellant,
v.
LABORERS' WELFARE FUND OF THE HEALTH AND WELFARE DEPARTMENT OF THE CONSTRUCTION AND GENERAL LABORERS' DISTRICT COUNCIL OF CHICAGO AND VICINITY, Defendant-Appellee

As Corrected.

Appeal from the Circuit Court of Cook County. 12 L 006838. The Honorable Sanjay T. Tailor Judge, presiding.

For Appellant: Douglas L. Prochnow, John A. Roberts, William R. Andrichik, Edwards Wildman Palmer LLP, Chicago, IL.

For Appellee: J. Peter Dowd, Justin J. Lannoye, George A. Luscombe III, Dowd, Bloch, Bennett & Cervone, Chicago, IL.

JUSTICE LAVIN delivered the judgment of the court, with opinion. Justices Hyman and Mason concurred in the judgment and opinion.

OPINION

LAVIN, J.

Page 692

[¶1] This interlocutory appeal arises from the trial court's order granting summary judgment in an insurance coverage lawsuit to defendant Laborers' Welfare Fund of the Health and Welfare Department of the Construction and General Laborers' District Council of Chicago and Vicinity. On appeal, plaintiff Centro Medico Panamericano, Ltd., an out-patient surgical center, contends that the trial court erroneously granted defendant's motion for summary judgment because defendant's service representatives made plaintiff an oral unambiguous promise about the extent of insurance coverage. Plaintiff also contends that the trial court erred in concluding that the Employee Retirement Income Security Act of 1974 (29 U.S.C. § 1001, et seq. (2000) (ERISA)), preempted plaintiff's claim for promissory estoppel. In addition, plaintiff contends that the trial court erred by considering inadmissible hearsay and failing to grant plaintiff's Illinois Supreme Court Rule 191(a) (eff. Jan. 4, 2013) motion to strike. We affirm.

[¶2] BACKGROUND

[¶3] We recite only those facts necessary to understand the issues raised on appeal. Between June 2007 and October 2011, plaintiff provided medical services for 21 procedures on 16 patients. Before each procedure, plaintiff placed a verification call to defendant's service representatives to verify whether the procedure was covered by each patient's health insurance policy. During the verification calls, plaintiff provided defendant with the provider's name, the patient's name, insurance information, and the procedure and services to be performed. Defendant responded by confirming coverage and the amount of benefits available for each procedure,

Page 693

which was a percentage of plaintiff's billed charges. Defendant paid plaintiff on each of the claims totaling $35,491.05, pursuant to the plan's " usual and customary charges" for out-of-network providers, including any applicable deductibles or coinsurance, which was significantly less than the amount billed. Upon payment, defendant also provided an explanation of benefits for each claim and explained why payments were not paid in full. Defendant also included information about its detailed appeal procedure, but no participant appealed.

[¶4] In June 2012, five years after the first disputed claim, plaintiff filed this promissory estoppel suit against defendant contending that it was entitled to approximately $98,000 more on its claims, arguing that defendant's service representatives orally promised that defendant would pay a fixed percentage of whatever amount plaintiff billed, no matter how high or excessive. In response, defendant filed a motion for summary judgment, including the affidavits of its claims director Lori Williams and expert Rebecca Busch, contending that plaintiff could not establish its promissory estoppel claim under Illinois law. Defendant also contended that because this dispute over the level of benefits paid to plaintiff related to an ERISA plan, plaintiff's claim was preempted.

[¶5] According to Williams' affidavit, defendant was a multiemployer ERISA welfare fund and provided for the payment to eligible participants of health benefits detailed in its written plan of benefits (the Plan). Defendant only paid benefits in accordance with the Plan as interpreted by the trustees or persons delegated by them to decide benefit issues in their sole discretion. The Plan prevented excessive charges by only allowing payment for " usual and customary charges" defined in the Plan. The definition of " usual and customary charges" depended on whether the provider was in-network or out-of-network. For in-network providers (PPOs), defendant had a negotiated rate for services. Defendant, however, had no negotiated rate with out-of-network providers, such as plaintiff. Therefore, to limit exposure to excessive claims from these out-of-network providers, the Plan would pay only " usual and customary charges" defined as a " charge that [was] no higher than the 90th percentile of the Plan's most currently ...


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