Teamcare Infusion Orlando, Inc. v. Humana Health Plans of Puerto Rico, Inc.
| Decision Date | 14 November 2017 |
| Docket Number | Civil No. 14–1741(DRD) |
| Citation | 296 F.Supp.3d 429 |
| Parties | TEAMCARE INFUSION ORLANDO, INC., Plaintiff v. HUMANA HEALTH PLANS OF PUERTO RICO, INC., et al., Defendants |
| Court | U.S. District Court — District of Puerto Rico |
Alan C. Gold, Alan C. Gold, PA, Coral Gables, FL, Michelle M. Castro–Rivera, Vanessa Medina–Romero, Rafael M. Santiago–Rosa, Marichal, Hernandez, Santiago, and Juarbe LLC, San Juan, PR, for Plaintiff.
Herman G. Colberg–Guerra, Frances R. Pesquera–Rivera, Pietrantoni Mendez & Alvarez, San Juan, PR, for Defendants.
Pending before the Court are Defendants' Motion for Summary Judgment (Docket No. 83), Plaintiff's Response to Motion for Summary Judgment (Docket No. 94), and finally Defendants' Reply to Plaintiff's Response to Motion for Summary Judgment (Docket No. 101). For the reasons set forth below, Defendants' Motion for Summary Judgment is hereby GRANTED .
On September 1, 2008, Humana Health Plans of Puerto Rico, Inc. ("Humana Health"), Humana Health Insurance of Puerto Rico, Inc. ("Humana Insurance") (jointly, "Humana") and Team Care Infusion Orlando, Inc. ("Teamcare") entered into an Ancillary Services Agreement ("Agreement"). (Docket No. 86, Exhibit B). Pursuant to the terms of the Agreement, Teamcare was authorized to provide services to Humana members enrolled in the Government of Puerto Rico's Reform Program and the Medicare Programs. (Id. ) The two plans are from separate jurisdictions. The Reform program is from the Government of Puerto Rico laws and regulations, while the Medicare Program is federal in nature. The Agreement states that all payment of claims shall be made in accordance with applicable Commonwealth of Puerto Rico and federal statutes and regulations, applicable to each one of the two sovereign governments. (Id. ) Additionally, the Agreement specifies that a provider may challenge any denial or payment of a claim to Humana within 45 days of payment. (Id. ) If the provider challenges a claim, Humana will review the claim and render a final decision with respect to the claim within 30 days of receipt of such information. (Id. )
On March 4, 2011, Teamcare filed an administrative complaint against Humana Health before the Health Insurance Administration of Puerto Rico ("ASES" by its Spanish acronym), in which Plaintiff asserted that Humana Health breached the terms of the Agreement by not paying certain claims from October 2009 to July 2010. (Docket No. 86, Exhibit C). Teamcare alleged that according to the terms of the Agreement between the parties "TeamCare would provide specialty pharmacy services for members of Humana, more specifically Puerto Rico Reforms members." (Id. ) Additionally, Plaintiff alleged that "[d]uring the time that TeamCare provided services (medications) to the Reform members that Humana was responsible to manage, Humana continuously breeched the terms of said agreement..." (Id. ) Teamcare requested damages for $105,623.73, which according to the administrative complaint, "represents only the contractual fees for services that TeamCare provided to members of Humana's Reform Program." (Id. at 2). Finally, the administrative complaint contained a handwritten address at the end of its second page specifying that Teamcare's address was in Sanford, Florida. (Id. ) On March 21, 2011, ASES issued a Notification of Complaint to the parties and set a deadline for Humana to file its answer. (Docket No. 102, Exhibit P).
Subsequently, on June 16, 2011, Teamcare's President, Mark Schneider, and Humana representatives attended a status conference at ASES. (Docket No. 86, Exhibit D). During the hearing, Teamcare provided Humana with a document that contained a list of unpaid claims, which Humana agreed to evaluate. (Id. )
In response, on September 26, 2011, Humana Health provided to Mr. Schneider an Excel spreadsheet evaluating the claims Teamcare previously delivered (the "First Evaluation".) (Docket No. 86, Exhibit E). The First Evaluation analyzed fifty five (55) individual Reform claims for services from 2009 and 2010. (Id. ) Additionally, Humana detailed in the First Evaluation whether each claim had been paid, paid in part, denied, and denied in part, in addition to the reasons for denial. (Id. ) Following Humana's position, on January 3, 2012, Mr. Schneider of Teamcare wrote an email to Humana stating that the First Evaluation contained information that did not merit denials and cited the outstanding balance due to Teamcare in the spreadsheet. (Docket No. 86, Exhibit H). Mr. Schneider also requested copies of the cancelled checks that were referenced in the spreadsheet. (Id. ) In response, Humana provided to Mr. Schneider copies of the cancelled checks. (Docket No. 86, Exhibit J).
On November 1, 2013, more than ten months thereafter, ASES issued a Resolution dismissing Teamcare's administrative complaint for procedural inactivity since July 25, 2011. (Docket No. 86, Exhibit K). The ruling contained an additional notice informing the party adversary affected by the decisions of its right to seek reconsideration within twenty (20) days or appeal ASES's determination before the Puerto Rico Court of Appeals within thirty (30) days. (Id. ) ASES notified the Resolution to Humana's representatives and to Teamcare's Puerto Rico representative at his local address. (Id. at 2).
Next, on October 1, 2014, Teamcare filed the present action for breach of contract against Humana. (Docket No. 1). On December 4, 2014, Humana responded to the complaint by filing a Motion to Dismiss based primarily on res judicata grounds and, in the alternative, that the claim was time barred. (Docket No. 24). While the Motion to Dismiss was pending, on May 27, 2016, Teamcare provided Humana with another list of the claims at issue for Humana to review. (Docket No. 86, Exhibit L). Accordingly, on July 11, 2016, Humana sent Teamcare another Excell spreadsheet evaluating the claims delivered to them (the "Second Evaluation".) (Docket No. 86, Exhibit M). On September 4, 2014, this Honorable Court issued an opinion denying in part and holding in abeyance in part Defendants' Motion to Dismiss . (Docket No. 35). Specifically, this Court held that, although all the requirements for res judicata were met in this case, there was a public policy exception in Puerto Rico to its application in situations where, as here, a case was dismissed for lack of prosecutions. (Id. ) Additionally, this Court found that the three year statute of limitations period established in Article 1867 of the Civil Code of Puerto Rico, 31 L.P.R.A. § 5297 was tolled in the instant case by the filing of the administrative complaint before ASES. (Docket No. 46).
Accordingly, the parties proceeded to conduct discovery. Humana served Teamcare with a series of interrogatories asking Teamcare to "provide copy of the claims", "evidence of submission of each claim to Humana" and "a copy of any response and/or denial of payment issued by Humana for each claim". (Docket 86, Exhibit N at 5). Moreover, Humana asked Teamcare to state whether it was in agreement with Humana's evaluation of each claim and, if not, to provide the reasons for disagreement and specific evidence to support its position. (Id. at 6). Teamcare responded to Humana interrogatories by providing the following documents: (i) failure to pay claims, including HCFA forms, (ii) EOPs, (iii) Account Receivable Reports and related documents evidencing payment and non-payment of claims, (iv) correspondence between the parties, and (v) miscellaneous documents supporting Plaintiff's claims. (Docket 86, Exhibit O).
On June 16, 2017, Humana filed a Motion for Summary Judgment . (Docket No. 83). Teamcare then filed its Response to the Motion for Summary Judgment on July 20, 2017 (Docket No. 94), to which Humana replied on August 16, 2017. (Docket No. 102).
Rule 56 of the Federal Rules of Civil Procedure provides that summary judgment should be entered where "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 judgment as a matter of law." FED. R. CIV. P. 56(c) ; see Celotex Corp. v. Catrett, 477 U.S. 317, 324–325, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). Pursuant to the clear language of the rule, the moving party bears a two-fold burden: it must show that there is "no genuine issue as to any material facts;" as well as that it is "entitled to judgment as a matter of law." Veda–Rodriguez v. Puerto Rico, 110 F.3d 174, 179 (1st Cir. 1997). A fact is "material" where it has the potential to change the outcome of the suit under governing law. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). A fact is "genuine" where a reasonable jury could return a verdict for the nonmoving party based on the evidence. Id. Thus, it is well settled that "the mere existence of a scintilla of evidence" is insufficient to defeat a properly supported motion for summary judgment. Id.
After the moving party meets this burden, the onus shifts to the non-moving party to show that there still exists "a trial worthy issue as to some material facts." Cortes–Irizarry v. Corporacion Insular, 111 F.3d 184, 187 (1st Cir. 1997).
At the summary judgment stage, the trial court examines the record Cadle Co. v. Hayes, 116 F.3d 957, 959–60 (1st Cir. 1997). "Credibility determinations, the weighing of the evidence, and the drawing of legitimate inferences from the facts are jury functions, not those of a...
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...of law. Gonzalez Figueroa v. J.C. Penney of P.R., Inc., 568 F.3d 313, 323 (1st Cir. 2009); Teamcare Infusion Orlando, Inc. v. Humana Health Plans of P.R., Inc., 296 F.Supp. 3d 429, 439 (D.P.R. 2017). Pursuant to the Erie doctrine, "in the absence of more convincing evidence of what the stat......