United States District Court, N.D. Indiana, South Bend Division
OPINION AND ORDER
JON E.
DEGUILIO, UNITED STATES DISTRICT COURT JUDGE
Plaintiff
William Emerick, proceeding pro se, filed this suit
against Defendant Anthem Insurance Companies, Inc., alleging
that Anthem failed to reimburse him and his now-deceased wife
for some of her medical expenses in accordance with their
joint health insurance policy, which itself is created under
the Employee Retirement Income Security Act
(“ERISA”), 29 U.S.C. § 1001, et
seq. Anthem has now filed for summary judgment on
Emerick's complaint. [DE 24] For the reasons stated
herein, the Court will grant summary judgment in favor of
Anthem.[1]
FACTUAL
BACKGROUND
The
Policy
Emerick
and his wife were joint beneficiaries of an employee welfare
benefit policy created under ERISA. The policy bars
beneficiaries from taking legal action to recover benefits
any later than three years after the date the relevant claims
are required to be furnished to Anthem. [DE 9-1 at 89]
Beneficiaries must give notice of a claim for benefits within
90 days of receiving covered services and provide the
necessary information for Anthem to determine benefits.
Id. at 80. Failure to abide by this deadline is not
fatal so long as the beneficiary demonstrates that the notice
was submitted as soon as reasonably possible. Id.
Under no circumstances, however, can a claim or related
information be submitted “later than one year after the
90 day filing period ends[.]” Id. In other
words, the absolute last day for a beneficiary to submit a
claim or supporting information is one year plus 90 days
after he or she receives covered services.
Before
taking legal action to recover benefits, beneficiaries must
exhaust the “grievance and appeals procedures, ”
which allow them to challenge Anthem's decision regarding
those benefits. Id. at 86-89.[2] Anthem will
resolve all grievances within twenty business days of their
receipt, plus another ten business days at most in the event
of an extension. Id. at 86-87. If the beneficiary is
not satisfied, he or she may then appeal the grievance
decision within 60 days. Id. at 87.
Emerick's
Claims
In late
2011 and early 2012, Emerick and his wife incurred expenses
for the following items related to her medical treatment: (1)
emergency treatment in December 2011 at Sanoviv Medical
Institute in Baja, Mexico; (2) subsequent ground
transportation to and treatment at the critical care unit of
Hospital Angeles in Tijuana, Mexico, which lasted from
mid-December 2011 until early January 2012; and (3)
transportation from the U.S.-Mexico border by both ground
ambulance and jet to a hospital in Goshen, Indiana, on
January 4, 2012. [DE 52 at 1-2] In total, Emerick maintains
these items cost him over $232, 000. Whether Emerick actually
incurred these expenses is not at issue, however. Instead, he
alleges that he submitted claims for reimbursement of these
expenses to Anthem, only to have his claims either ignored or
wrongfully rejected. Specifically, he alleges he submitted a
claim on March 13, 2012, labeled Claim No. 130020142800. [DE
6 at 2]
Anthem
reviewed the claims history associated with Emerick's
wife and found no record of Claim No. 130020142800.
[Affidavit of Michelle Kersey ¶ 6] But the record
indicates that at least two claims pertaining to his
wife's treatment were submitted. First, a letter from
Anthem to Emerick's wife, dated November 10, 2012,
acknowledged that she had filed an “International
Claim, ” but that the claim could not be processed
because it needed to be translated into English. [DE 51-1 at
85] The letter does not identify the international claim by
any label or number, however. Second, regarding
transportation from the border to Indiana on January 4, 2012,
it appears Emerick's wife submitted a claim form dated
January 23, 2013, and attached two documents: a letter from
Care Medical Transportation (the ambulance company that
transported her from the border to an airfield in southern
California) informing her that she owed $1, 309.00 for
services provided on January 4, 2012; and an invoice from Air
Evac International (the company that flew her from California
to Indiana) noting that the $24, 000 trip had been paid for.
[DE 26-1 at 31, 33][3] In response to this claim, Anthem sent
Emerick three letters requesting additional information, the
last of which was dated June 7, 2013. [DE 26-1 at 34-37]
Emerick then answered with a letter of his own on August 3,
2013, explaining his efforts to secure the information sought
by Anthem for both the international claim and the
transportation claim. Id. at 39-45. The record
contains no evidence that the parties communicated beyond
this August 2013 letter.[4] Emerick filed this lawsuit on November
1, 2017. [DE 6]
STANDARD
On
summary judgment, the moving party bears the burden of
demonstrating 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
“material” fact is one identified by the
substantive law as affecting the outcome of the suit.
Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248
(1986). A “genuine issue” exists with respect to
any material fact when “the evidence is such that a
reasonable jury could return a verdict for the nonmoving
party.” Id. Where a factual record taken as a
whole could not lead a rational trier of fact to find for the
non-moving party, there is no genuine issue for trial, and
summary judgment should be granted. Matsushita Elec.
Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587
(1986) (citing Bank of Ariz. v. Cities Servs. Co.,
391 U.S. 253, 289 (1968)). In determining whether a genuine
issue of material fact exists, this Court must construe all
facts in the light most favorable to the non-moving party and
draw all reasonable and justifiable inferences in that
party's favor. Jackson v. Kotter, 541 F.3d 688,
697 (7th Cir. 2008); King v. Preferred Tech. Grp.,
166 F.3d 887, 890 (7th Cir. 1999).
DISCUSSION
A
beneficiary of an ERISA-based insurance policy may bring an
action under 29 U.S.C. § 1132(a)(1)(B) “to recover
benefits due to him under the terms of his plan, to enforce
his rights under the terms of the plan, or to clarify his
rights to future benefits under the terms of the
plan.”[5] The parties do not dispute whether Emerick
is a “beneficiary, ”[6] and here, he seeks to
recover benefits he believes are due to him under the policy.
Anthem argues, however, that Emerick failed to submit any of
the claims at issue or otherwise improperly submitted them.
Alternatively, Anthem argues that even if Emerick had
properly submitted the claims, his lawsuit is time-barred by
the policy's three-year limitation on legal actions. The
Court agrees that, at the very least, Emerick cannot recover
on his claims because he filed this lawsuit long after the
policy's window to take legal action closed. See
Grammer v. Aetna Life Ins. Co., 286 Fed.Appx. 947, 949
(7th Cir. 2008) (“Employee welfare plans can impose a
time limitation on suits so long as the time period is
reasonable.”) (citing See Doe v. Blue Cross Blue
Shield United of Wis., 112 F.3d 869, 874-75 (7th Cir.
1997)).
As
outlined above, beneficiaries have one year and 90 days (at
most) from the date of covered services to submit their
claims to Anthem. The policy further makes clear that
beneficiaries “may not take legal action against
[Anthem] to receive benefits … [l]ater than three
years after the date the claim is required to be furnished to
[Anthem].” [DE 9-1 at 89] Reading these provisions
together, Emerick had a total of four years and 90 days from
when his wife received services to file the instant lawsuit.
He filed this action on November 1, 2017, which means that
the related services must have been provided to his wife on
or after August 1, 2013. The challenged claims, however,
pertain to services ...