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August 20, 2001


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.


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 (1989).

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 Richstone requested that Guardian reimburse him for a total of $4,615.00 of which $30.00 was later withdrawn.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 that the 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.).

Richstone sent a letter to Guardian on July 24, 1996, purportedly explaining why the November tests and treatments were necessary. (Plaintiff's Affidavit, Ex. 6). Richstone also asserted that the bills he submitted to Guardian, containing his diagnosis of the patient, should be considered adequate documentation by themselves.

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 ...

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