Wolfe v. Carefirst of Md., Inc.
| Decision Date | 04 January 2013 |
| Docket Number | Civil No. CCB-10-2606 |
| Parties | EDWARD WOLFE, as representative and executor of THE ESTATE OF FLORENCE WOLFE v. CAREFIRST OF MARYLAND, INC. d/b/a CAREFIRST BLUECROSS BLUESHIELD |
| Court | U.S. District Court — District of Maryland |
Plaintiff Edward Wolfe, representative and executor of the estate of Florence Wolfe, filed this breach of contract action against defendant CareFirst alleging that CareFirst's denial of claims for Ms. Wolfe's care in a nursing home during the last years of her life violated her CareFirst issued Catastrophic Health Expense Policy. The parties have filed cross-motions for summary judgment.1 For the reasons set forth below, the plaintiff's motion will be denied and the defendant's motion will be granted.
In 1986, Florence Wolfe purchased a Catastrophic Health Expense Policy from CareFirst of Maryland. (See Policy, ECF No. 126-2.) If covered medical expenses related to an illness or injury surpassed $50,000 in any one year period, the policy covered the next $250,000 in expenses over a two-year period, at which point another $50,000 deductible was triggered, whichwas again followed by a two-year, $250,000 coverage period. The policy covers all "medically necessary" treatment provided at an inpatient hospital, as well as treatment at an "extended care facility" ("ECF") provided that "admission to the ECF [was] within 14 days of a prior covered hospital stay;" the "prior covered hospital stay was at least 3 days long;" and the treatment at the ECF was "for continued treatment of the same illness or injury for which benefits are eligible." (Id. at 11, 20.) The policy also covers mental health treatment. (Id. at 19.) However, the policy states, on the cover page, that it (Id.) The policy further states that it excludes "services mainly for custodial care or rest cures, regardless of whether the custodial care is ordered by a physician, [or] necessary to maintain the insured's present condition." (Id. at 22.) Finally, the policy defines "medically necessary" as "those services and supplies provided by a hospital or practitioner to identify or treat an illness or injury which has been diagnosed or is reasonably suspected and are . . . [among other characteristics] [c]onsistent with the diagnosis and treatment of the insured's condition . . . [and] [t]he most appropriate supply or level of service which can be safely provided for the insured." (Id. at 31.)
In 1999, Ms. Wolfe moved into an assisted living facility close to her son, Edward, in Texas. In November 2006, having been diagnosed with Alzheimer's disease, Ms. Wolfe had to be hospitalized for episodes of syncope (fainting) and a fractured right shoulder. (See Hospital Records, ECF No. 127-1.) Ms. Wolfe was discharged five days later, and her treating physician, Dr. George Markus, recommended she be transferred to an extended care facility, the Victoria Gardens nursing home, because she could no longer care for herself given the progression of her Alzheimer's. (See id.; Markus Dep., ECF No. 128-6, at 42-45,79-81.) In 2007 and 2008, Edward Wolfe filed claims on behalf of his mother for her care at Victoria Gardens. (See Wolfe Decl.,ECF No. 128-7, ¶¶ 2-11.) Wolfe documented claims for expenses well in excess of the $50,000 deductible required to trigger the policy (in fact, Wolfe presents claims surpassing a second $50,000 deductible). CareFirst denied these claims, asserting that Ms. Wolfe's treatment at Victoria Gardens was not covered by the policy. CareFirst also disputes the amounts claimed by Wolfe and asserts that, even if the claims had all been applied, the $50,000 deductible still would not have been met.
Wolfe filed a claim with the Maryland Insurance Administration (MIA) challenging CareFirst's denial of the claims. (See IPRO Report, ECF Nos. 124-8 & 144.) The MIA ordered an independent review of the claims by a private contractor, IPRO. A report was created by Dr. Francis Foca, an independent medical expert employed by IPRO, who determined that CareFirst was, overall, correct in its denial of the claims because they were mainly for custodial care services related to Ms. Wolfe's Alzheimer's, but that some of the denied claims were for periods of medically necessary rehabilitation treatment following hospital stays for acute injuries and illnesses, including recovery from the initial shoulder injury and from pneumonia. (See id.) Dr. Markus, her physician, indicated that he believed Ms. Wolfe's admittance to Victoria Gardens was medically necessary because of her deteriorating mental faculties. (Markus Dep. at 45.)
In September 2009, Ms. Wolfe filed suit against CareFirst claiming breach of contract because of its denial of coverage for her continued stay at Victoria Gardens since her hospitalization in 2006. Ms. Wolfe passed away in December 2010 and her son, Edward, as representative and executor of her estate, was substituted as plaintiff.
Federal Rule of Civil Procedure 56(a) provides that summary judgment should be granted "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." The Supreme Court has clarified that this does not mean that any factual dispute will defeat the motion. "By its very terms, this standard provides that the mere existence of some alleged factual dispute between the parties will not defeat an otherwise properly supported motion for summary judgment; the requirement is that there be no genuine issue of material fact." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247-48 (1986) (emphasis in original). Whether a fact is material depends upon the substantive law. See id.
"A party opposing a properly supported motion for summary judgment may not rest upon the mere allegations or denials of [his] pleadings, but rather must set forth specific facts showing that there is a genuine issue for trial." Bouchat v. Baltimore Ravens Football Club, Inc., 346 F.3d 514, 522 (4th Cir. 2003) (alteration in original) (quotations omitted). The court must "view the facts and draw reasonable inferences 'in the light most favorable to the party opposing the [summary judgment] motion,'" Scott v. Harris, 550 U.S. 372, 378 (2007) (alteration in original) (quoting United States v. Diebold, 369 U.S. 654, 655 (1962)), but the court also must abide by the "affirmative obligation of the trial judge to prevent factually unsupported claims and defenses from proceeding to trial." Drewitt v. Pratt, 999 F.2d 774, 778-79 (4th Cir. 1993) (internal quotation marks omitted).
"When both parties file motions for summary judgment, the court applies the same standards of review." Loginter S.A. Y Parque Indus. Agua Profunda S.A. Ute v. M/V NOBILITY,177 F. Supp. 2d 411, 414 (D. Md. 2001) (citing Taft Broad. Co. v. United States, 929 F.2d 240, 248 (6th Cir. 1991); ITCO Corp. v. Michelin Tire Corp., 722 F.2d 42, 45 n.3 (4th Cir. 1983)). "The role of the court is to 'rule on each party's motion on an individual and separate basis, determining, in each case, whether a judgment may be entered in accordance with the Rule 56 standard.'" Id. (quoting Towne Mgmt. Corp. v. Hartford Acc. & Indem. Co., 627 F. Supp. 170, 172 (D. Md. 1985)).
Before assessing the evidence the parties have adduced to support their respective motions for summary judgment, it is necessary to briefly address their motions to strike the other party's "expert designations."2 Wolfe moves to strike the independent report authored by Dr. Francis J. Foca, at the request of the Maryland Insurance Administration, assessing CareFirst's denial of the claim at issue in this case (IPRO Report, ECF Nos. 124-8 & 144). Wolfe contends that the report is unreliable ("a farce") and that it was not timely produced in discovery. In its response, CareFirst states, and Wolfe does not contest, that Wolfe has been in possession of the report since 2009 and that he produced the report to CareFirst in 2011. In addition, CareFirst has submitted a sworn affidavit by Dr. Foca that states he is the author of the report and that it is "an independent medical review of a complaint filed with the Maryland Insurance Administration by Florence Wolfe, a resident of Texas, regarding her claim for benefits under a Catastrophic Health Expense Policy issued to her by CareFirst." (Foca Aff., ECF No. 143-2, ¶¶ 2-3.) The affidavit also lists Dr. Foca's extensive medical credentials which corroborate those contained in the IPRO report. (Id. ¶¶ 6-15.) The court is satisfied that CareFirst did not improperly withhold discoverable information from Wolfe and that the IPRO Report is reliable, admissible evidencewritten by a qualified medical expert. Accordingly, Wolfe's motion to strike the IPRO Report will be denied.3
Likewise, CareFirst moves to strike Wolfe's submission of testimony by Dr. George M. Markus, although Dr. Markus is a qualified, veteran doctor, because he apparently did not read the CareFirst policy or any of Ms. Wolfe's medical records from Victoria Gardens prior to the morning of his deposition. To the extent that Wolfe seeks to admit testimony by Dr. Markus stating that the treatment Ms. Wolfe received at Victoria Gardens was medically necessary, not custodial care, and covered by the policy, such testimony is inadmissible because Dr. Markus did not have sufficient knowledge of Ms. Wolfe's treatment at Victoria Gardens to offer an opinion characterizing it.
Under Fed. R. Evid. 702 and Daubert v. Merrell Dow Pharm., Inc., 509 U.S. 579 (1993), expert testimony must be "reliable," and this determination "depend[s] upon the unique circumstances of the expert testimony involved." Westberry v. Gislaved Gummi AB, 178 F.3d 257, 261 (4th Cir. 1999) (citing ...
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