United States District Court, D. Utah Central Division
IHC HEALTH SERVICES, INC. dba LDS HOSPITAL, Plaintiff,
INTERMOUNTAIN UNITED FOOD AND COMMERCIAL WORKERS AND FOOD INDUSTRY HEALTH FUND, Defendant.
DECISION AND ORDER DENYING PLAINTIFF'S MOTION FOR SUMMARY
JUDGMENT ON THE RECOVERY OF BENEFITS CLAIM (ECF NO. 23),
GRANTING DEFENDANT'S MOTION FOR PARTIAL SUMMARY JUDGMENT
ON THE FIDUCIARY DUTY CLAIM (ECF NO. 24), AND RESERVING
JUDGMENT ON THE MOTIONS FOR SUMMARY JUDGMENT ON THE FAILURE
TO PROVIDE PLAN DOCUMENTS CLAIM (ECF NOS. 23 &
J. FURSE United States Magistrate Judge.
the Court are Plaintiff IHC Health Services,
Inc.'s (“IHC”) Motion for Summary Judgment
(ECF No. 23) and Defendant Intermountain United Food and
Commercial Workers and Food Industry Health Fund's
(“Intermountain”) Motion for Partial Summary
Judgment (ECF No. 24). IHC did not file a reply in support of
its Motion for Summary Judgment by the April 18, 2018
deadline; instead, it filed its reply memorandum late,
without seeking an extension of time or leave to so.
(See Order Granting Stipulated Mot. for Extension of
Time for Briefing re Pl.'s Mot. for Summ. J., ECF No. 30
(setting April 18, 2018 deadline to file reply); IHC Reply to
Def.'s Mem. in Opp'n, ECF No. 33 (filed April 20,
2018)). The Court disregards IHC's untimely reply
memorandum and considers all timely-filed briefs on the
parties' Motions for Summary Judgment.
Complaint asserts three claims against Intermountain under
the Employee Retirement Income Security Act of 1974, as
amended (“ERISA”): (1) recovery of plan benefits
under 29 U.S.C. § 1132(a)(1)(B) (first cause of action);
(2) breach of fiduciary duties under 29 U.S.C. §§
1104, 1109, and 1132(a)(2) and (3) (second cause of action);
and failure to produce plan documents under 29 U.S.C.
§§ 1024(b)(4) and 1132(c)(1) (third cause of
action). (Compl., ECF No. 2.) Intermountain seeks summary
judgment on IHC's second cause of action for breach of
fiduciary duties and third cause of action for failure to
produce plan documents. (Intermountain Mot. for Partial Summ.
J. (“Intermountain Mot.”) 2, ECF No. 24.) In
response to Intermountain's Motion, IHC concedes summary
judgment on its second cause of action for breach of
fiduciary duties. (IHC Opp'n to Mot. for Partial Summ. J.
(“IHC Opp'n”) 1, ECF No. 28 (“On Count
II, [IHC] concedes that summary judgment is
appropriate.”). Because the parties agree that the
Court should grant Intermountain's Motion on IHC's
second cause of action for breach of fiduciary duties, the
Court GRANTS summary judgment in favor of Intermountain as to
also moves for summary judgment on its first cause of action
for recovery of plan benefits and third cause of action for
failure to produce plan documents. (IHC Mot. for Summ. J.
(“IHC Mot.”) 1, ECF No. 23.) Intermountain also
seeks summary judgment on IHC's third cause of action for
failure to produce plan documents. (Intermountain Mot. 1-2,
ECF No. 24.)
the remaining two causes of action, for the reasons addressed
below, the Court DENIES IHC's Motion as to the first
cause of action for recovery of plan benefits, and RESERVES
judgment on IHC's Motion and Intermountain's Motion
as to the third cause of action for failure to produce plan
documents. The parties should come to the final pretrial
conference with a proposal about how to proceed.
Court grants summary judgment when the evidence shows
“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). “In an ERISA case like
this, where both parties move for summary judgment and
stipulate that no trial is necessary, ‘summary judgment
is merely a vehicle for deciding the case; the factual
determination of eligibility for benefits is decided solely
on the administrative record, and the non-moving party is not
entitled to the usual inferences in its favor.'”
Cardoza v. United of Omaha Life Ins. Co., 708 F.3d
1196, 1201 (10th Cir. 2013) (quoting LaAsmar v. Phelps
Dodge Corp. Life, Accidental Death & Dismemberment &
Dependent Life Ins. Plan, 605 F.3d 789, 796 (10th Cir.
ERISA cases, the Court generally confines its review to the
administrative record. Adamson v. Unum Life Ins.
Co., 455 F.3d 1209, 1212 (10th Cir. 2006). However, the
Court may consider “extra-record materials related to
an administrator's dual role conflict of interest.”
Murphy v. Deloitte & Touche Grp. Ins. Plan, 619
F.3d 1151, 1162 (10th Cir. 2010).
opposing IHC's motion for summary judgment, Intermountain
objects to certain of IHC's facts-supported by citations
to the administrative record in this case-as inadmissible,
unauthenticated, and/or containing hearsay. (Intermountain
Opp'n to Pl.'s Mot. for Summ. J.
(“Intermountain Opp'n”) 6-9, ECF No. 32.)
Intermountain's objections lack merit, and the Court
overrules them. The Court reviews the entire administrative
record considered by the plan administrator in ERISA cases,
including exhibits that may otherwise be excluded under the
Federal Rules of Evidence. See, e.g.,
Black v. Long Term Disability Ins., 582 F.3d 738,
746 n.3 (7th Cir. 2009) (“The Federal Rules of
Evidence, however, do not apply to an ERISA
administrator's benefits determination, and we review the
entire administrative record, including hearsay evidence
relied upon by the administrator.”); Bigley v.
Ciber, Inc., No. 11-CV-0055-RBJ-MJW, 2012 WL 5494660, at
*6 (D. Colo. Nov. 13, 2012) (unpublished) (“The
administrative record is what it is. If it contains hearsay
that would be inadmissible in a court of law under the
Federal Rules of Evidence, so be it. The rules of evidence do
not apply to what the plan or third party administrator may
consider in evaluating a . . . claim. If they rely on
unreliable evidence, then that could and should be considered
by the reviewing court in making a determination as to
whether to affirm or reverse the decision of the
administrators.”); Malenski v. Standard Ins.
Co., No. CIV-11-408-SPS, 2012 WL 4485331, at *1 (E.D.
Okla. Sept. 27, 2012) (unpublished) (overruling evidentiary
objections to joint administrative record).
also submits evidence outside of the administrative record in
the form of a declaration from D.A. Jensen, former president
and fund manager for JAS, Inc. (“JAS”), which
provided third party administrative services for
multi-employer benefit plans operated pursuant to ERISA,
including Intermountain's Plan at issue in this case.
(App. of Evid., Tab 1, Jensen Decl., ECF No. 32-1.) Mr.
Jensen's declaration addresses the relationship between
JAS and Intermountain, and the third party administrative
services it performed on Intermountain's behalf. (See
id.) While the Court generally confines its review in an
ERISA case to the administrative record, Adamson,
455 F.3d at 1212, the Court may consider materials outside
the record if they relate to a plan administrator's
“dual role conflict of interest.”
Murphy, 619 F.3d at 1162. The Court will consider
Mr. Jensen's declaration since it informs the applicable
standard of review in this case. The Court notes that IHC has
not presented any evidence outside of the administrative
record concerning Intermountain's alleged conflict of
October 12, 2013 through November 12, 2013, K.M. received
treatment at LDS Hospital. (IHC Opp'n, Resp. to
Undisputed Material Fact No. 3, ECF No. 28.) Plaintiff IHC
operates LDS Hospital. (IHC Opp'n, Resp. to Undisputed
Material Fact No. 1, ECF No. 28.) Defendant
Intermountain's Plan, a multi-employer health and welfare
plan, provided health coverage to K.M., a union employee
whose membership entitled her to coverage, at the time of
treatment. (IHC Mot., Undisputed Material Fact No. 4, ECF No.
23; IHC Opp'n, Resp. to Undisputed Material Fact Nos.
1-4, ECF No. 28; Compl. ¶ 7, ECF No. 2; Answer ¶ 7,
ECF No. 6; AR 149.) This case arises out of a dispute
between IHC and Intermountain over the amount Intermountain
owes IHC for the care and treatment of K.M. Intermountain
notes that IHC named only the trust fund as a Defendant and
not the “plan” as required under ERISA.
(Intermountain Opp'n, Resp. to Undisputed Material Fact
Nos. 2 & 19, ECF No. 32; Intermountain Mot. 6 n.1, ECF
No. 24.) However, Intermountain concedes that for purposes of
the Motions for Summary Judgment, IHC “sued the proper
party.” (Id.) While not specifically addressed
in any of the briefs, the parties agree that LDS Hospital,
where K.M. received treatment, is an out-of-network provider
per the terms of Intermountain's Plan. K.M. remains
obligated to pay for all services provided to her by IHC for
which Intermountain refuses to pay. (AR 2.)
Intermountain Plan is an ERISA covered plan. (IHC Opp'n,
Resp. to Undisputed Material Fact No. 2, ECF No. 28; Answer
¶ 3, ECF No. 6; AR 87.) Intermountain's Board of
Trustees is the Plan administrator. (AR 82, 84.)
Intermountain's Summary Plan Description
(“SPD”) indicates that the Board of Trustees
operates and administers the Plan and that the Board
has full power to interpret the Plan and all Plan documents,
agreements, rules, and regulations, and to decide all
questions concerning the Fund, including, but not limited to,
the eligibility of any person to participate in the Fund and
his or her entitlement to Plan benefits. The Board's
interpretations and decisions concerning these matters are
final and conclusive, so long as they are made in good faith
and are not arbitrary or capricious.
Intermountain Opp'n 11-12, ECF No. 32.) The SPD further
states that “[o]nly the full Board of Trustees (or its
authorized designee) is authorized to interpret the terms of
the Plan. The Board of Trustees (or its authorized designee)
has sole discretion to decide questions involving the Plan,
including questions regarding  eligibility for
benefits.” (AR 12-13; Intermountain Opp'n 12, ECF
No. 32.) The Board delegated its “authority to
determine the appropriate payments to make to providers
making claims for benefits under the health plan . . . and to
respond to appeals from [those] determinations to JAS. (App.
of Evid., Tab 1, Jensen Decl. ¶ 6, ECF No. 32-1.) JAS
acted as third-party administrator for Intermountain's
Plan. (IHC Mot., Undisputed Material Fact No. 3, ECF No. 23;
Intermountain Opp'n, Add'l Material Fact No. 1, ECF
No. 32; App. of Evid., Tab 1, Jensen Decl. ¶¶ 2-3,
ECF No. 32-1; Compl. ¶ 5, ECF No. 2; Answer ¶¶
5, 6, ECF No. 6.)
third-party administrator for the Intermountain Plan, JAS
reviewed claims for eligibility and payment on behalf of the
Plan's participants and beneficiaries and provided
financial reports and claims analysis to the Plan's Board
of Trustees. (Intermountain Opp'n, Add'l Material
Fact No. 2, ECF No. 32; App. of Evid., Tab 1, Jensen Decl.
¶ 3, ECF No. 32-1.) JAS received a fixed monthly fee for
its services; it did not receive incentive payments or
bonuses for denying claims. (Intermountain Opp'n,
Add'l Material Fact No. 4, ECF No. 32; App. of Evid., Tab
1, Jensen Decl. ¶ 7, ECF No. 32-1.) JAS, as the
third-party administrator for Intermountain's Plan,
determined the amount of benefits to pay to IHC on K.M.'s
behalf for the treatment she received from LDS Hospital.
(Intermountain Opp'n, Add'l Material Fact No. 5, ECF
No. 32; App. of Evid., Tab 1, Jensen Decl. ¶ 6, ECF No.
32-1.) JAS did not receive a reward or payment for making a
particular determination on K.M.'s claim. (Intermountain
Opp'n, Add'l Material Fact No. 5, ECF No. 32; App. of
Evid., Tab 1, Jensen Decl. ¶ 8, ECF No. 32-1.) JAS
provided similar services for other funds, in addition to
Intermountain. (App. of Evid., Tab 1, Jensen Decl. ¶ 4,
ECF No. 32-1.)
billed charges for K.M.'s treatment totaled $78, 458.99.
(IHC Mot., Undisputed Material Fact No. 6, ECF No. 23; AR
104, 110, 112, 118, 120, 123, 126, 133, 141, 153, 178 &
183.) Based on a review conducted by Data iSight,
Intermountain, through JAS, determined that the allowable
expense for K.M.'s claim was $27, 738.80, and
Intermountain paid IHC 50% of the allowed amount, or $13,
869.40. (IHC Mot., Undisputed Material Fact Nos. 8, 11, ECF
No. 23; IHC Opp'n, Resp. to Undisputed Material Fact No.
8, ECF No. 28; Intermountain Opp'n, Resp. to Undisputed
Material Fact Nos. 10-11, ECF No. 32; App. of Evid., Tab 1,
Jensen Decl. ¶¶ 6, 8, ECF No. 32-1; AR 108, 114,
125, 126, 133, 141, 151-55, 178.)
claims the Plan provides that it will pay inpatient hospital
treatment at an out-of-network provider at 60% of the Usual,
Customary, and Reasonable charges (“UCR”); mental
health treatment at 80% of the UCR; and emergency room
treatment at 95% of the UCR. (IHC Mot., Undisputed Material
Fact Nos. 12-14, ECF No. 23; AR 15.) IHC cites a Plan
document dated October 1, 2003 that states the change took
effect January 1, 2003. (AR 5, 11.) Intermountain claims an
amendment to the Plan IHC relies on took effect June 1, 2006,
and governed payment for K.M.'s 2013 treatment at LDS
Hospital. (Intermountain Opp'n, Resp. to Undisputed
Material Fact Nos. 12-14, ECF No. 32; AR 187-89.) The notice
of the amendment indicates that the plan will pay for
inpatient hospital treatment at an out-of-network provider at
50% of the UCR; that it will pay for “all other medical
services, ” including mental health treatment, at 50%
of the UCR; and that it will pay for emergency room treatment
at rates ranging from 75%-85% depending on whether the
beneficiary has Plan A, B, or C. (AR 189.) IHC cites to the
Plan A schedule of benefits in the 2003 plan in its briefs,
(see AR 14-17 (“Plan A Schedule of
Benefits”)), but never specifically indicates whether
K.M. had Plan A, B, or C. (See Intermountain
Opp'n, Resp. to Undisputed Material Fact No. 14, ECF No.
Intermountain's SPD defines the UCR as:
a charge which falls within the common range of fees billed
by a majority of health care providers for a procedure in a
given geographic region, or which is justified based on the
complexity or the severity of treatment for a specific case,
as determined from time to time by the Board.
(IHC Mot., Undisputed Material Fact No. 17, ECF No. 23; AR
27.) Data iSight, a third party used to review ...