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Emerick v. Anthem Insurance Companies, Inc.

United States District Court, N.D. Indiana, South Bend Division

March 27, 2019

WILLIAM EMERICK, pro se, Plaintiff,
v.
ANTHEM INSURANCE COMPANIES, INC., Defendant.

          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 ...


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