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Douglas W. Griffin, As Executor of the Estate of William L. Griffin v. Corning Incorporated

August 16, 2011

DOUGLAS W. GRIFFIN, AS EXECUTOR OF THE ESTATE OF WILLIAM L. GRIFFIN, PLAINTIFF,
v.
CORNING INCORPORATED, DEFENDANTS.



The opinion of the court was delivered by: Michael A. Telesca United States District Judge

DECISION and ORDER

INTRODUCTION

Plaintiff, Douglas W. Griffin ("Plaintiff"), brings this action pursuant to the Employee Retirement Security Act of 1974, 29 U.S.C. §§ 1001 et seq. ("ERISA"), as executor of his father, William L. Griffin's estate. Plaintiff seeks payment for medical care received by his father prior to his death at Robert Packer Hospital (the "Hospital") in Sayre, Pennsylvania, from December 31, 2008 to February 17, 2009, the date of his death. Compl., Docket No. 1. Plaintiff's father was eligible for benefits under an employee welfare benefits plan (the "Plan") governed by ERISA, sponsored by Defendant, Corning Incorporated, and administered by the Corning Benefits Committee (the "Plan Administrator").

Defendant moves for summary judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure ("Rule 56") claiming that it is entitled to judgment as a matter of law, as the undisputed facts reveal that Plaintiff is not entitled to payment under the Plan because Medicare provided payment-in-full to the Hospital and he has no outstanding financial liability with respect to his father's treatment at the Hospital from December 31, 2008 to February 17, 2009. Plaintiff opposes the motion, citing language in the Plan which he contends entitles him to payment regardless of whether his father's estate has any financial liability to the Hospital. For the reasons set forth herein, this Court grants Defendant's Motion for Summary Judgment and Plaintiff's Complaint is hereby dismissed with prejudice.

FACTUAL BACKGROUND AND PROCEDURAL HISTORY

After reviewing Defendant's statement of facts*fn1 , Plaintiff's submissions in opposition to this motion, and the entire administrative record, this Court finds that the following facts are not in dispute.

Plaintiff's father, as the spouse of a retired Corning Incorporated employee, was eligible to receive certain benefits under the Plan. Pursuant to the Corning Medicare Supplemental Plan, the Plan coordinates payment of certain medical expenses with Medicare when a plan participant turns 65. Under this scheme, Medicare becomes the primary insurer and the Plan provides secondary coverage. Plaintiff's father was over 65 at all relevant times, and therefore, his primary insurer was Medicare and the Plan provided secondary insurance coverage.

The Plan provides "full discretionary authority" to the Plan Administrator to determine all questions about the Plan, including questions regarding the eligibility for benefits. The Plan also authorizes the Plan Administrator to engage a third party administrator or insurance company and to delegate its discretionary authority to such an entity. In this case, pursuant to an Administrative Services Agreement, the Plan Administrator delegated its discretionary authority to UnitedHealthcare Service Corp. ("UHC").

The Plan, in pertinent part, provides as follows: "If you or members of your family are covered by ... a government medical insurance program, ... your total benefits from all sources will be limited to 100% of reasonable and customary charges for the medical expenses incurred." The Plan also provides, "When a Corning medical plan is the secondary payer, it pays benefits so that your total medical plan does not exceed 100% of reasonable and customary charges for the covered service." UHC "pays 80% of the difference between the Medicare-allowable amounts and Medicare-paid amounts after a $250 annual deductible is met, up to $300,000 per person, per lifetime."

Pursuant to 42 U.S.C. § 1395cc, the Secretary of the Department of Health and Human Services is authorized to enter into agreements with hospitals or other service providers whereby the service provider is required to accept payment from Medicare for Medicare recipients based on a Medicare approved adjustment. Accordingly, based on these agreements, Medicare will "allow" certain charges and then pay all or a portion of the "Medicare-allowable amount." A secondary insurance plan, like the instant Plan, may then pay all or a portion of the amount (if any) Medicare allowed but did not pay. In this case, the Plan will pay 80% of the difference between what Medicare allows and what Medicare actually pays, after a $250 annual deductible.

Plaintiff's father was hospitalized at Robert Packer Hospital from December 31, 2008 until his death on February 17, 2009. Robert Packer Hospital submitted an "Itemized Statement" to Medicare following his hospitalization, which listed charges of $267,505.50*fn2 . Medicare accepted the charges and adjusted the claim by $208,735.22, leaving a balance of $58,770.28. Based on a prior agreement with the Hospital, Medicare then paid the hospital $58,770.28. Also based on this agreement, the outstanding balance due to the Hospital was $0.00, because the Hospital had agreed to accept the amount of money Medicare "allowed" ($58,770.28), which it paid to the Hospital.

In a letter dated March 31, 2010, following his father's death and his appointment as executor of his father's estate, Plaintiff filed a claim with UHC requesting payment of $165,992.18 for his father's medical care at Robert Packer Hospital. Plaintiff attached a form provided by Medicare to the Hospital describing its payments and adjustments for the services received by his father. Plaintiff interpreted the form to read that the amount "allowed" by Medicare was the full amount initially charged to Medicare by the Hospital. Accordingly, he asserted that the amount "allowed" by Medicare was $266,573.00 and the amount paid by Medicare was $58,770.29. Accordingly, he contended that his father's estate was entitled to 80% of the difference between these numbers, less the $250 deductible under the Plan, or $165,992.17.

UHC responded to Plaintiff's claim on June 3, 2010. UHC explained that it had not issued a payment to him because Medicare had paid the Hospital charges, as adjusted, in full. They specifically informed Plaintiff that he had no financial liability to the Hospital based on his father's hospitalization.

In a letter dated June 16, 2010, Plaintiff reiterated his contentions and again requested payment pursuant to his interpretation of the Plan. Plaintiff did not dispute, nor does he dispute now, that his father's estate has no financial liability to the Hospital. Rather, he contended that the estate is entitled to payment under the plan, ...


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