The opinion of the court was delivered by: Victor Marrero, U.S.D.J.
Plaintiffs in this Consolidated action, Diagnostic Medical Association
and Dr. Geoffrey Richstone (hereinafter "Richstone"), assert that
Defendant, Guardian Life Insurance Company of America (hereinafter
"Guardian"), inadequately reimbursed Richstone for medical treatment that
he allegedly provided. Guardian has moved for summary judgment pursuant
to Rule 56 of the Federal Rules of Civil Procedure on two causes of
action relating to medical services Richstone provided to Abraham
Rodriguez (hereinafter "Rodriguez"). For the reasons set forth below,
Guardian's motion for summary judgment is granted, and the two claims
pertaining to the purported treatment of Rodriguez are hereby dismissed.
I. FACTS AND PROCEDURAL HISTORY
The underlying facts giving rise to Richstone's complaint are not in
dispute. Guardian provided major medical insurance to Rodriguez pursuant
to Group Policy No. 218847 (hereinafter "the Plan"), and the insurance
policy fell within the scope of the Employee Retirement Income Security
Act of 1974 (hereinafter "ERISA"), 29 U.S.C. § 1001, et seq. (See
Defendant's Notice of Motion for Summary Judgment, dated May 8, 2000
(hereinafter "Defendant's Notice of Motion"), Ex. D). Section
1132(a)(1)(B) of ERISA allows suits to recover benefits under an
applicable plan. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 108
Richstone alleges that he provided medical care to Rodriguez on three
separate occasions, two visits on November 27-28, 1995 and one on
December 4, 1995. According to Richstone, his treatment of Rodriguez
included a number of procedures such as a chest x-ray, echocardiogram,
EKG, spirometry, venipuncture and blood tests. (See Defendant's Notice of
Motion, Ex. I).
The parties' dispute focuses on the aftermath of Richstone's alleged
treatment of Rodriguez and on Guardian's decision to deny Richstone
reimbursement for his claimed procedures.
Richstone's medical office submitted claims to Guardian for the alleged
costs of the services on March 20, 1996 for Rodriguez's November visits
and on April 2, 1996 for the December visit. (Plaintiff's Affidavit in
Opposition, dated June 6, 2000 (hereinafter "Plaintiff's Affidavit"),
Exs. 1- 3). Richstone requested that Guardian reimburse him for a total
of $4,615.00 of which $30.00 was later withdrawn. (Defendant's Statement
Pursuant to Rule 56.1, dated May 8, 2000 (hereinafter "Defendant's Rule
56.1 Statement"), at ¶ 5). When he submitted these original claim
forms, Richstone provided no documentation or information establishing
tests were actually performed or that they were even necessary.
In response to the claim forms, Guardian sent Richstone a
correspondence on April 10, 1996 (hereinafter the "April 10 Letter"),
stating that it could not reimburse Richstone's claims without additional
information. (Defendant's Notice of Motion, Ex. E). The April 10 Letter
contains language which the Court believes to be essential to resolving
Richstone's claims in the present case. That letter from Guardian
explained that Richstone was required to submit "a written statement from
the attending physician which documents the medical necessity of this
service. This statement must include the diagnosis, prognosis, and
estimated duration of treatment." More importantly, the April 10 Letter
unambiguously stated that more documentation would be required for
Richstone to substantiate his claims: "Please submit all medical
treatment records and pertinent information for this treatment." (Id.).
Richstone replied to the April 10 Letter by sending a few pages of
handwritten notes, much of which was largely illegible, and what Guardian
acknowledges to be blood test results from Rodriguez's November 27
visit. (Defendant's Notice of Motion, Ex. F). Noticeably absent from his
reply, however, were treatment records, test results or any other
documentation for several other procedures that Richstone alleges he
provided and for which he was seeking reimbursement.
Guardian gathered all of the documentation that Richstone provided and
submitted it, along with the claims, to Professional Peer Review, Inc.
(hereinafter "PPR"), an independent company that employs practicing
physicians to review claims for medical insurers. On May 24, 1996, PPR
issued its findings on Richstone's claims. PPR found that the charges
were improperly billed and documented. Specifically, PPR concluded that
Richstone's documentation lacked historical information, that a number of
his claimed procedures (the EKG and Spirometry) were not indicated, that
other procedures were not documented, and that a number of claims were
improperly unbundled.*fn1 (Defendant's Notice of Motion, Ex. I).
Richstone asserts that PPR is not an impartial or independent reviewer
and that it is in fact beholden to the insurance companies that retain
it. In addition, Richstone contends that the review was too perfunctory
to be fair and accurate. (See Plaintiff's Counter Statement Pursuant to
Rule 56.1, dated June 7, 2000 (hereinafter "Plaintiff's Counter
Statement"), at ¶ 9).
On June 11, 1996, Guardian sent Richstone "Explanation of Benefits"
forms (hereinafter "EOB" or "EOBs"), which detailed his November 1995
claims and how much of each claim Guardian was willing to reimburse. Out
of a total claim of $4,625.00, Guardian paid $461.00. (Defendant's Notice
of Motion, Ex. J). When it felt that a particular item should be denied,
Guardian provided a "Remark Code" stating that "[c]harges exceed the
reasonable and customary allowance," or in one case that, "[t]hese
charges have been combined with those of the primary procedure." (Id.).
On August 13, 1996, Guardian issued an EOB for Rodriguez's December
tests and treatment. (Defendant's Notice of Motion, Ex. K). The EOB
denied all claims, stating that "[c]harges will be considered after we
receive the requested information." The "requested information" refers to
the requests in the April 10 Letter which sought all medical records and
pertinent information related to the alleged treatment of Rodriguez for
the November procedures. Richstone responded by sending another letter of
explanation on November 26, 1996, additional handwritten notes and blood
test results, apparently from Rodriguez's December visit. (Id., Ex. G).
Guardian collected all of the documents relating to Rodriguez's
December visit and submitted them to a second peer review organization,
the Medical Review Institute of America (hereinafter "MRI"). MRI issued
its report on October 24, 1996, concluding also that Richstone's claims
were improperly documented and that the need for tests had not been
established. (Id. Ex. L). MRI's reviewer stated that the "[pliroblem
history [is] mostly illegible . . . The rationale for the lab tests in
this case is not apparent, because the history is not legible." (Id.).
On the basis of this second peer review, Guardian issued an additional
EOB on November 21, 1996 which reimbursed Richstone $88.00 for $575.00 of
claimed charges. This EOB also remarked that "[c]harges exceed
reasonable/Customary amount or rate in certificate book" and ...