Saldana v. Aetna U.S. Healthcare

• Decision Date: 02 August 2002
• Docket Number: No. 3:01CV502BN.,3:01CV502BN.
• Citation: 233 F.Supp.2d 812
• Parties: Charlene SALDANA Plaintiff v. AETNA U.S. HEALTHCARE Defendant
• Court: U.S. District Court — Southern District of Mississippi

233 F.Supp.2d 812

Charlene SALDANA Plaintiff v. AETNA U.S. HEALTHCARE Defendant

No. 3:01CV502BN.

United States District Court, S.D. Mississippi, Jackson Division.

August 2, 2002.

Everette Scott Verhine, Verhine & Verhine, Vicksburg, MS, W. Richard Johnson, Prewitt, Johnson & Vance, Vicksburg, MS, for plaintiff.

Robert T. Gordon, Jr., Mitchell, McNutt & Sams, PA, Flowood, MS, for defendant.

OPINION AND ORDER

BARBOUR, District Judge.

This cause is before the Court on the Motion of Defendant for Summary Judgment. Having considered the Motion, Response, Rebuttal, attachments to each, and supporting and opposing authority, the Court finds that the Motion is well taken and should be granted.

I. Background and Procedural History

In June of 1997, Felicia Saldana, the daughter of Charlene Saldana, was injured in a motor vehicle accident. She was treated by University of Mississippi Medical Center ("UMC") where she died on June 23, 1997. At the time of the accident, Felicia Saldana was a beneficiary under the Cooper Industries, Inc. ("Cooper Industries") welfare benefit plan in which her mother Charlene Saldana ("Plaintiff"), an employee of Cooper Industries, was a participant.¹

On July 2, 1997, Defendant Aetna U.S. Healthcare ("Aetna"), the claims administrator of the subject benefit plan, received a claim for payment of benefits in the amount of $26,625.66 for services rendered by UMC to Felicia Saldana. Thereafter, and pursuant to the terms and conditions set forth in the Plan, Aetna sent a letter to Plaintiff requesting information regarding the circumstances of the accident including whether other insurance coverage or benefits were available to the claimant and whether the claimant had recovered from a third party on account of the accident.² Aetna also requested that Plaintiff sign and return a Reimbursement Agreement. See id. Plaintiff did not respond to the requests of Aetna with regard to her claim. Nor did Plaintiff respond to the requests for information made by Aetna on August 27, 1997, or October 8, 1997.

On November 12, 1999, Aetna was notified by Cooper Industries that it had been served a writ garnishing the wages of Plaintiff to recover a judgment against her in favor of University Hospital. Aetna accepted the information as confirmation that no other insurance or source of third-party recovery existed with regard to the motor vehicle accident in which Felicia Saldana was injured, processed and paid a claim to UMC for $344.36 on December 15, 1999. Aetna later realized that the amount paid on the claim was the amount of garnishment rather of the amount of the actual claim and, upon resubmittal of the original claim by UMC, sent payment of $25,804.79 on March 7, 2000.

Notably, at no time between the date on which the claim was first submitted by UMC and the date on which it was ultimately paid by Aetna, did Plaintiff request a review of her claim as was her right under the Plan. See id. at 10064 (providing that, "if [a claimant] do[es] not receive any response to [her] claim within 90 days after ... initially fil[ing] it with Aetna," a claimant "can" follow the review procedure set forth in the Plan). Instead, on March 12, 2001, months after the date on which the claim was paid and only after the writ for garnishment of her wages was served on her employer, Plaintiff filed a lawsuit against Aetna in the Circuit Court for the First Judicial District of Hinds County, Mississippi. In her complaint, Plaintiff alleged that she "was served with a summons and a complaint filed by [UMC in which UMC] ... sought monetary damages on an open account." See ¶ 3 of State Court Complaint attached to Notice of Removal. Plaintiff further alleged that the debt was "finally paid on or about 2/23/2000," see id at ¶ 4, but that Plaintiff was damaged by the negligence of Aetna in failing to "timely pay her insurance claims after being notified said claim(s) were pending with [UMC]...." See id. at ¶ 6. Plaintiff asserted state law causes of action against Aetna for negligence, and gross negligence, and sought compensatory and punitive damages. See id. at ¶¶ 7 & 8.

On June 27, 2001, Aetna ("Defendant") removed the case to this Court pursuant to 28 U.S.C. §§ 1331 and 1441, on ground that "the policy which is the subject of this action ... is an employer benefit plan ... within the meaning and scope of and government by ERISA" and that Plaintiff's claims against it were therefore preempted by ERISA. See Notice of Removal. Plaintiff did not file a Motion to Remand, but instead, amended her Complaint to assert a cause of action under ERISA. See Motion of Defendant for Summary Judgment, Exhibit "C," Attachment "A," Amended Complaint, ¶¶ 6 & 7. Defendant filed the instant Motion for Summary Judgment on April 18, 2002.

II. Legal Standard

Rule 56 of the Federal Rules of Civil Procedure provides, in relevant part, that summary judgment "shall be rendered forthwith if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law." FED. R. CIV. P. 56(c). The United States Supreme Court has held that this language "mandates the entry of summary judgment, after adequate time for discovery and upon motion, against a party who fails to make a sufficient showing to establish the existence of an element essential to that party's case, and on which that party will bear the burden of proof at trial." Celotex Corp. v. Catrett, 477 U.S. 317, 322, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986); see also Moore v. Mississippi Valley State Univ., 871 F.2d 545, 549 (5th Cir.1989); Washington v. Armstrong World Indus., 839 F.2d 1121, 1122 (5th Cir.1988).

The party moving for summary judgment bears the initial responsibility of informing the district court of the basis for its motion and identifying those portions of the record in the case which it believes demonstrate the absence of a genuine issue of material fact. Celotex, 477 U.S. at 323, 106 S.Ct. 2548. The movant need not, however, support the motion with materials that negate the opponent's claim. Id. As to issues on which the non-moving party has the burden of proof at trial, the moving party need only point to portions of the record that demonstrate an absence of evidence to support the non-moving party's claim. Id. at 323-24, 106 S.Ct. 2548. The non-moving party must then go beyond the pleadings and designate "specific facts showing that there is a genuine issue for trial." Id. at 324, 106 S.Ct. 2548.

Summary judgment can be granted only if everything in the record demonstrates that no genuine issue of material fact exists. It is improper for the district court to "resolve factual disputes by weighing conflicting evidence, ... since it is the province of the jury to assess the probative value of the evidence." Kennett-Murray Corp. v. Bone, 622 F.2d 887, 892 (5th Cir. 1980). Summary judgment is also improper where the court merely believes it unlikely that the non-moving party will prevail at trial. National Screen Serv. Corp. v. Poster Exchange, Inc., 305 F.2d 647, 651 (5th Cir.1962).

III. Analysis

In her Amended Complaint (hereinafter "Complaint"), Plaintiff alleged that, (1) although "finally paid [by Defendant] on or about 2/23/2000," her "indebtedness owed to University Hospitals was not timely paid by ... Defendant," Complaint ¶ 4, and (2) the "negligent[] fail[ure by Defendant] to timely pay her insurance claims ... proximately caused [her] damages and ... was an impermissible abuse of discretion as defined by ERISA." Complaint ¶ 6 (emphasis added). The Court construes these allegations as claims of (1) state law negligence, and (2) breach of fiduciary duties under 29 U.S.C. § 1101 through 29 U.S.C. § 1114.³ Neither Plaintiff nor Defendant addressed Plaintiff's state law claim. However, in an abundance of caution, the Court considers whether Plaintiff's state law claim is preempted under ERISA. See 29 U.S.C. § 1144(a) (providing that ERISA "shall supercede any and all state laws insofar as they may now or hereafter relate to any employer benefit plan"). Federal Courts have been directed to broadly construe the "deliberately expansive" preemption provision of ERISA. See Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 46, 107 S.Ct. 1549, 95 L.Ed.2d 39 (1987) (holding that the deliberately expansive language of the preemption provision was "designed to `establish pension plan regulation as exclusively a federal concern.'") (quoting Alessi v. Raybestos-Manhattan, Inc., 451 U.S. 504, 523, 101 S.Ct. 1895, 68 L.Ed.2d 402 (1981)); Hubbard v. Blue Cross & Blue Shield Ass'n, 42 F.3d 942, 945 (5th Cir.1995). Under this provision, state law causes of action are barred in the event "(1) the state law claim addresses an area of exclusive federal concern, such as the right to receive benefits under the terms of an ERISA plan; and (2) the claim directly affects the relationship between the traditional ERISA entities-the employer, the plan and its fiduciaries, and the participants and beneficiaries." Hubbard, 42 F.3d at 945.

The preemptive scope of ERISA, however, is not without limits. The United States Supreme Court has found that "[s]ome state actions may affect employee benefit plans in too tenuous, remote, or peripheral a manner to warrant a finding that the law `relates to' the plan." Shaw v. Delta Air Lines, Inc., 463 U.S. 85, 100 n. 21, 103 S.Ct. 2890, 77 L.Ed.2d 490 (1983). Therefore, to fall within the ambit of ERISA preemption, the state law causes of action set forth by the plaintiff in his complaint, must "relate to" the employee benefit plan. See Ingersoll-Rand Co. v. McClendon, 498 U.S. 133, 138-39, 111 S.Ct. 478, 112 L.Ed.2d 474 (1990). Under this test, a "state law cause of action relates to an employee benefit plan whenever it has `a connection with or reference to such a plan.'" Hubbard, 42...