Publix Super Mkts. v. Figareau
| Decision Date | 14 September 2020 |
| Docket Number | Case No: 8:19-cv-545-T-27AEP |
| Court | U.S. District Court — Middle District of Florida |
| Parties | PUBLIX SUPER MARKETS, INC., Plaintiff, v. PATRICIA FIGAREAU and FRANTZ PAUL, individually and on behalf of L.P., a minor, MARIA D. TEJEDOR, and DIEZ-ARGUELLES & TEJEDOR, P.A., Defendants. |
BEFORE THE COURT are Plaintiff Publix Super Markets, Inc.'s Motion for Summary Judgment (Dkt. 93), Defendants' Opposition (Dkt. 103), Defendants' Motion for Summary Judgment (Dkt. 94), and Publix' Response in Opposition (Dkt. 102). Upon consideration, Publix' motion is GRANTED. Defendants' motion is DENIED.
This is an action by Publix under the Employee Retirement Income Security Act (ERISA) to obtain reimbursement of medical benefits paid by its employee group benefits plan on behalf of L.P., Defendant Paul's dependent. It is undisputed that, consistent with its terms, the plan paid benefits on behalf of L.P. for treatment of an injury she suffered at birth caused by third parties. Paul and Defendant Figareau, represented by Defendants Tejedor and Diez-Arguelles & Tejedor, P.A., settled an underlying state court negligence action against the third parties and recovered settlement proceeds. Under the unambiguous terms of the plan, the settlement triggered an obligation to reimburse the plan for the benefits paid on behalf of L.P. Notwithstanding, Paul and Figareau refused to reimburse the plan, prompting this action. In defending against Publix' claim for reimbursement, Defendants rely on preempted state law in an attempt to relitigate the underlying state court negligence action and limit the plan's right to reimbursement. However, under ERISA and in accordance with the plan's terms, they are obligated to reimburse the plan for the total amount of benefits paid on behalf of L.P. from the settlement proceeds, which are held in trust by Defendants' counsel.
Publix is the sponsor and "Plan Administrator" of its self-funded Group Health Benefit Plan (the "Plan"), which provides medical expense benefits to eligible employees and their dependents. (Dkt. 14-1 ¶¶ 3-6; Dkt. 1-3 at p. 67). Under its terms, the Plan "may issue payments for covered medical, prescription and other health care claims incurred by a member for a covered injury or illness caused by 'another party' . . . , but the member agrees to fully reimburse the Plan if and when the member receives payment from another party in connection with such injury or illness."1 (Dkt. 1-3 at p. 44). Specifically, the Plan includes a provision titled "First Priority Right of Subrogation and/or Reimbursement," which provides:
Any amounts recovered are subject to subrogation or reimbursement. The Plan is subrogated to all rights the member may have against that other person or another party and is entitled to first and full priority reimbursement out of any recovery to the extent of the Plan's payments. In addition, the Plan shall have a first priority equitable lien against any recovery to the extent of benefits paid and to be payable in the future. The Plan's first priority equitable lien supersedes any right that the member may have to be made whole. In other words, the Plan is entitled to the right offirst reimbursement out of any recovery the member procures or may be entitled to procure regardless of whether the member has received full compensation for any of his or her damages or expenses, including attorneys' fees or costs and regardless of whether the recovery is designated as payment for medical expenses or otherwise. Additionally, the Plan's right of first reimbursement will not be reduced for any reason, including attorneys' fees, costs, comparative or contributory negligence, limits of collectability or responsibility, characterization of recovery as pain and suffering or otherwise. The Plan's right of first reimbursement shall not be defeated by the common fund doctrine or similar doctrine. . . .
(Id. at p. 45). Further, "recovery" is defined as:
Any and all monies identified, paid or payable to the member through or from another party by way of judgment, award, settlement, covenant, release or otherwise (no matter how those monies may be characterized, designated or allocated) to compensate for any losses caused by, or in connection with, such member's injury or illness. A recovery exists as soon as any fund is identified as compensation for a member from another party.
(Id. at p. 59). These terms, which entitle the Plan to reimbursement "out of any recovery," including a settlement "to compensate for any losses caused by, or in connection with, [a] member's injury" caused by "another party," are clear and unambiguous.
Blue Cross and Blue Shield (BCBS) assists with the Plan's operations, including reimbursement, but does not assume financial responsibility for the payment of medical expenses covered by the Plan. (Dkt. 14-1 ¶¶ 7-8; Dkt. 1-3 at p. 67). BCBS reviews claims to determine whether benefit payments should be restored to the Plan out of the proceeds of settlements with third parties who caused a member's injuries. (Dkt. 93-9 at pp. 2-4 ¶¶ 4-10, 14-15; Dkt. 1-3 at p. 68).
As a Publix employee, Defendant Paul enrolled his and Defendant Figareau's minor child, L.P., in the Plan. (Dkt. 14-1 ¶ 5). The Plan paid $88,846.39 in medical benefits related to an injury L.P. sustained at birth. (Id. ¶ 9). Defendants Tejedor and Diez-Arguelles & Tejedor, P.A.represented Paul and Figareau in a negligence action against the medical providers and hospital. (Id. ¶¶ 9-10; Dkt. 93-1). In that action, Paul and Figareau alleged that a "shoulder dystocia was encountered" at the time of L.P.'s delivery and that, as a result of the defendants' negligence, she sustained a "significant brachial plexus injury." (Dkt. 93-1 ¶¶ 25-32). Based on these allegations, Paul and Figareau settled the case with the hospital for $95,000, and with the medical providers for $750,000. (Dkt. 93-2 at p. 3; Dkt. 93-4 at pp. 2-3). Both settlement agreements included releases of claims related to the alleged negligence.2 The state court approved the settlements.
(Dkts. 93-3, 93-5). The Plan was not notified of the settlements until "after the fact." (Dkt. 14-1 ¶ 13).3
To repair and treat the brachial plexus injury, L.P. underwent several surgical procedures and received occupational and vocational therapy, paid for by the Plan. See, e.g., (Dkt. 93-9 at pp. 5-7 ¶¶ 18-24; Dkt. 93-8 at pp. 7-10, 17, 23, 27-28, 33-34). On the Plan's behalf, BCBS identified the benefits claims relating to L.P.'s brachial plexus injury and gathered information about the incident from Figareau. (Dkt. 93-9 at pp. 3-4 ¶¶ 6-13, p. 11). BCBS sent several letters to Tejedor to notify Defendants of the Plan's reimbursement interest in any settlement proceeds and the updated lien amounts, including the $88,846.39 Publix seeks reimbursement of in this action. (Id. at p. 7 ¶¶ 26-27; Dkt. 93-10 at pp. 63-130). The letters included statements of benefits, supported by operative reports and clinical information. (Dkt. 93-9 at p. 7 ¶ 25, pp. 12-131; Dkt. 93-10). Defendants did not dispute that the Plan's payments were related to the brachial plexus injury orthe alleged negligence of the medical providers and hospital. (Dkt. 93-9 at p. 8 ¶ 28). Defendants did not reimburse the Plan, and Publix filed suit.
In Count I, Publix seeks an equitable lien by agreement on the settlement proceeds as reimbursement of the Plan's payment. (Dkt. 1 ¶¶ 14-15, 26-28). Specifically, Publix alleges that Defendants' refusal to reimburse the amount paid by the Plan "violates the Plan" and entitles Publix to enforce its terms under § 502(a)(3) of ERISA, 29 U.S.C. § 1132(a)(3). (Id. ¶ 28).4 Publix moves for summary judgment, contending that an equitable lien by agreement in the amount of $88,846.39 should be imposed on the settlement proceeds held in trust by Defendants' counsel. (Dkt. 93). Defendants acknowledge in their motion for summary judgment that a lien by agreement is warranted but contend it should be limited to the "reasonable value" of the "surgical treatment" of L.P. (Dkt. 94 at p. 3). After review, I find Defendants' contention is without merit and Publix is entitled to an equitable lien by agreement in the full amount paid.
Summary judgment is appropriate where "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 genuine factual dispute exists only if a reasonable fact-finder 'could find by a preponderance of the evidence that the [non-movant] is entitled to a verdict.'" Kernel Records Oy v. Mosley, 694 F.3d 1294, 1300 (11th Cir. 2012) (citation omitted). A fact is material if it may affect the outcome of the suit under the governing law. Allen v. Tyson Foods, Inc., 121 F.3d 642, 646 (11th Cir. 1997).
The moving party bears the initial burden of showing, by reference to materials on file, that there are no genuine disputes of material fact. Hickson Corp. v. N. Crossarm Co., Inc., 357 F.3d 1256, 1260 (11th Cir. 2004) (citation omitted). If the movant adequately supports its motion, the burden shifts to the nonmoving party to show specific facts that raise a genuine issue for trial. Dietz v. Smithkline Beecham Corp., 598 F.3d 812, 815 (11th Cir. 2010). The evidence presented must be viewed in the light most favorable to the nonmoving party. Ross v. Jefferson Cty. Dep't of Health, 701 F.3d 655, 658 (11th Cir. 2012). "Although all justifiable inferences are to be drawn in favor of the nonmoving party," Baldwin Cty. v. Purcell Corp., 971 F.2d 1558, 1563-64 (11th Cir. 1992), "inferences based upon speculation are not reasonable," Marshall v. City of Cape Coral, 797 F.2d 1555, 1559 (11th Cir. 1986).
Further, the terms of an ERISA plan "must be enforced as written unless the Plan conflicts with the policies underlying ERISA or application of the common law is 'necessary to...
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