Aetna Life Ins. Co. v. Guerrera

CourtUnited States District Courts. 2nd Circuit. United States District Court (Connecticut)
Decision Date05 August 2020
Docket Number3:17-CV-00621 (KAD)
PartiesAETNA LIFE INSURANCE COMPANY Plaintiff, v. NELLINA GUERRERA, et al., Defendants.

NELLINA GUERRERA, et al., Defendants.

3:17-CV-00621 (KAD)


August 5, 2020


Kari A. Dooley, United States District Judge

This action involves claims by the Plaintiff, Aetna Life Insurance Company ("Aetna"), that as a "Medicare Advantage Organization" ("MAO"), it is entitled to be reimbursed for payments made on behalf of Defendant Nellina Guerrera for medical care after she sustained injuries as a result of a slip and fall on the premises of a store operated by Defendant Big Y Foods, Inc. ("Big Y"). Specifically, Aetna asserts that it was entitled to reimbursement from the proceeds of a settlement of the personal injury action brought by Guerrera against Big Y and herein sues Guerrera, Big Y, and Carter Mario Injury Lawyers ("Carter Mario"), Attorney Danielle Wisniowski, and Attorney Sean Hammil all of whom represented Guerrera in the underlying personal injury litigation.1 Pending before the Court is Aetna's motion for partial summary judgment and the Defendants' motion for summary judgment. For the reasons that follow, Aetna's motion for partial summary judgment is GRANTED. The Defendants' motion for summary judgment is DENIED in part and GRANTED in part.

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Standard of Review

The standard under which courts review motions for summary judgment is well-established. "The court shall grant summary judgment 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). A fact is "material" if it "might affect the outcome of the suit under the governing law," while a dispute about a material fact is "genuine" if "the evidence is such that a reasonable jury could return a verdict for the nonmoving party." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986).

Significantly, the inquiry being conducted by the Court when reviewing a motion for summary judgment focuses on "whether there is the need for a trial—whether, in other words, there are any genuine factual issues that properly can be resolved only by a finder of fact because they may reasonably be resolved in favor of either party." Id. at 250. As a result, the moving party satisfies his burden under Rule 56 "by showing . . . that there is an absence of evidence to support the nonmoving party's case" at trial. PepsiCo, Inc. v. Coca-Cola Co., 315 F.3d 101, 105 (2d Cir. 2002) (per curiam) (internal quotation marks omitted). Once the movant meets his burden, the nonmoving party "must set forth specific facts demonstrating that there is a genuine issue for trial." Wright v. Goord, 554 F.3d 255, 266 (2d Cir. 2009) (internal quotation marks omitted). "[T]he party opposing summary judgment may not merely rest on the allegations or denials of his pleading" to establish the existence of a disputed fact. Id.; accord Lujan v. Nat'l Wildlife Fed'n, 497 U.S. 871, 888 (1990). "[M]ere speculation or conjecture as to the true nature of the facts" will not suffice. Hicks v. Baines, 593 F.3d 159, 166 (2d Cir. 2010) (citations omitted; internal quotation marks omitted). Nor will wholly implausible claims or bald assertions that are unsupported by evidence. See Carey v. Crescenzi, 923 F.2d 18, 21 (2d Cir. 1991); Argus Inc. v. Eastman Kodak Co., 801

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F.2d 38, 45 (2d Cir. 1986). "[T]here is no issue for trial unless there is sufficient evidence favoring the nonmoving party for a jury to return a verdict for that party. If the evidence is merely colorable, or is not significantly probative, summary judgment may be granted." Anderson, 477 U.S. at 249-50 (citations omitted).

In determining whether there exists a genuine dispute as to a material fact, the Court is "required to resolve all ambiguities and draw all permissible factual inferences in favor of the party against whom summary judgment is sought." Johnson v. Killian, 680 F.3d 234, 236 (2d Cir. 2012) (quoting Terry v. Ashcroft, 336 F.3d 128, 137 (2d Cir. 2003)). "In deciding a motion for summary judgment, the district court's function is not to weigh the evidence or resolve issues of fact; it is confined to deciding whether a rational juror could find in favor of the non-moving party." Lucente v. Int'l Bus. Machines Corp., 310 F.3d 243, 254 (2d Cir. 2002).

Allegations and Procedural History

By complaint dated April 13, 2017, Aetna alleges as follows. In February 2015, Guerrera allegedly sustained personal injuries at the Big Y store in Monroe, Connecticut for which she sought and received medical care. Aetna, as an MAO, operates a Medicare Advantage health insurance plan ("MAO Plan"), in which Guerrera was enrolled and through which she maintained health insurance. Following her accident at the Big Y, Aetna paid approximately $9,854.16 in medical expenses on behalf of Guerrera. Guerrera retained the law firm of Carter Mario and/or attorneys Wisniowski and Hammil to bring a personal injury action against Big Y, which they did. The personal injury action was settled for $30,000.00.

Beginning in September 2015, prior to the settlement, Aetna began to place the Defendants on notice that it was asserting a lien against any recovery or settlement in the case for the value of the medical expenses it covered. On March 10, 2016, Big Y allegedly agreed that it would not send

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the full amount of any settlement to Guerrera or her attorneys without first addressing Aetna's claim. Notwithstanding, in September 2016, Big Y sent the full settlement amount of $30,000.00 to Guerrera and/or her lawyers. Neither Guerrera nor Big Y reimbursed Aetna for the covered expenses.

Aetna asserts, in Count One, that it is entitled to be reimbursed for the conditional payments made on behalf of Guerrera for her medical expenses. It brings this claim pursuant to the Medicare Secondary Payer Act ("MSP Act"), 42 U.S.C. § 1395y(b).

On July 5, 2017, the Defendants moved to dismiss the complaint in its entirety on the basis that, inter alia, the Private Cause of Action provision of the MSP Act, 42 U.S.C. § 1395y(b)(3)(A), does not give MAOs, like Aetna, the right to seek or receive reimbursement for medical expenses paid to enrollees. The Court (Hall, J.)2 disagreed and in a thorough 38-page decision, determined that an MAO, such as Aetna, could seek reimbursement for medical expenses pursuant to the Private Cause of Action provision of the MSP Act— "[T]he court concludes that the Private Cause of Action provision unambiguously permits suit by MAOs and, further, that even if it was ambiguous the [Center for Medicare and Medicaid Services ("CMS")] regulation that addresses MAO enforcement mechanisms, section 422.108(f), grants MAOs the right to sue under the Private Cause of Action provision." Aetna Life Ins. Co. v. Guerrera, 300 F. Supp. 3d 367, 378 (D. Conn. 2018). In so holding, the Court examined the legislative history of the statute, the regulations issued by CMS with respect to the statute, and relevant, though relatively scant, case law which discusses these issues. Accordingly, the MSP Act claim was permitted to proceed, but only against Big Y as an alleged "primary plan" under the MSP Act. The Court retained jurisdiction over the state law claims as to the remaining defendants.

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On April 3, 2018, as directed by the Court, Aetna filed an amended complaint to clarify its claims and to specify against whom the claims were alleged. The amended complaint, consisting of the same substantive allegations, includes three counts: Count One, the MSP Act claim, against Big Y; Count Two, a state law breach of contract claim, against Guerrera and Carter Mario; and Count Three, a state law breach of fiduciary duty claim, against all Defendants.

On September 17, 2018, all Defendants filed a motion for summary judgment as to all counts and Aetna filed a motion for partial summary judgment pertaining to Count One, the MSP Act claim. Those motions are decided herein.

What the Court is Not Deciding

As a preliminary matter, in both its motion for summary judgment and its opposition to Aetna's motion for summary judgment, Big Y asserts anew the arguments advanced in the previously decided motion to dismiss. Indeed, counsel for the Defendants conceded as much at oral argument on October 10, 2019. However, counsel for the Defendants also, though leery of putting words in Judge Hall's mouth, believed that Judge Hall had invited the Defendants to re-assert these legal arguments during a hearing held on June 8, 2018. Alternatively, the Defendants asked the Court to revisit the issues, "law of the case" notwithstanding. The Court has reviewed the transcript of the June 8, 2018 hearing before Judge Hall. There is some suggestion that these arguments could be raised at the summary judgment stage of the litigation. But the suggestion appears in the context of further fact development or in the context of Connecticut's anti-subrogation law. The Court does not read the transcript as an invitation to simply re-litigate the issues already decided. Nor is this Court inclined to revisit these issues. See Bank of Am. v. Pastorelli-Cuseo, 2017 WL 4678184, at *2 (D. Conn. Oct. 17, 2017) ("The [law of the case] doctrine 'applies to issues that have been decided either expressly or by necessary implication' . .

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. ." (quoting DeWeerth v. Baldinger, 38 F.3d 1266, 1271 (2d Cir. 1994)); Johnson v. Holder, 564 F.3d 95, 99 (2d Cir. 2009) ("The law of the case doctrine commands that 'when a court has ruled on an issue, that decision should generally be adhered to by that court in subsequent stages in the same case' unless 'cogent and compelling reasons militate otherwise.'" (citation omitted)).

Here, the scope of the MSP Act and whether the Private Cause of Action provision allows MAOs to seek reimbursement from primary plans is an issue on...

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