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RUSSO v. ABINGTON MEM. HOSP. HEALTHCARE PLAN

October 4, 1995

SAMUEL A. RUSSO, Administrator of the Estate of Eric B. Fountain
v.
ABINGTON MEMORIAL HOSPITAL HEALTHCARE PLAN c/o PENSION COMMITTEE, ABINGTON MEMORIAL HOSPITAL, and UNITED STATES HEALTHCARE SYSTEMS of PENNSYLVANIA, INC. a/k/a US HEALTHCARE, INC. and d/b/a HMO OF PENNSYLVANIA



The opinion of the court was delivered by: POLLAK

 POLLAK, J.

 October 4, 1995

 Before the court are separate motions by the defendants, Abington Memorial Hospital Healthcare Plan and United States Healthcare Systems of Pennsylvania, Inc., to dismiss aspects of the complaint of Samuel A. Russo, the administrator of the estate of Eric B. Fountain.

 I

 As is usual in considering a motion to dismiss, the following account of the facts of this case will assume that the facts are as alleged in Mr. Russo's complaint. This case arises from a dispute about who is to pay for the very large medical bills allegedly incurred by Mr. Fountain following his admission to the Albert Einstein Medical Center on or about January 22, 1990 as a result of a stab wound. Mr. Fountain was hired as an employee of the Abington Memorial Hospital on October 18, 1989, and hence received health insurance coverage through the hospital's health insurance plan, the Abington Memorial Hospital Healthcare Plan ("Abington Healthcare Plan," or "the Plan"), one of the defendants in this case. The Plan offered two forms of health-care benefits: a traditional, or "indemnity," insurance plan self-funded by Abington Memorial Hospital, and a health maintenance organization plan provided through an agreement between Abington Healthcare Plan and United States Healthcare Systems of Pennsylvania, Inc. ("U.S. Healthcare"), the other defendant.

 Russo alleges that Fountain became eligible for Abington Healthcare Plan benefits on January 1, 1990, and that Albert Einstein Medical Center's employees were told that Fountain was covered under the Plan's indemnity policy when he was admitted to the hospital. After Fountain's admission, however, Russo alleges that employees of Abington Memorial Hospital "directed, encouraged, assisted and/or aided a family member of Fountain's to sign and backdate a [U.S. Healthcare] enrollment form so that the effective date of the [U.S. Healthcare] enrollment would be January 1, 1990." Amended Complaint, P 18. Fountain remained in the hospital for two months, purportedly incurring a hospital bill in the amount of $ 291,233.05. (The itemized bill, which is attached to the Amended Complaint as an exhibit, is some fifty pages in length.) U.S. Healthcare allegedly paid a portion of Fountain's medical bills but refused to pay the remainder; it is not clear whether Fountain ever made a claim under Abington Healthcare Plan's indemnity policy.

 Fountain died some months after leaving the hospital, in September 1990. Russo was appointed as the administrator of Fountain's estate in August 1993. Russo then proceeded to seek information on Fountain's insurance coverage from both Abington Memorial Hospital and U.S. Healthcare. Through his attorney, he wrote letters to Abington Memorial Hospital's Human Resources Department in September and October 1993, requesting information on Fountain's insurance coverage and personnel records, specifically including "any applicable benefit booklet or other information regarding healthcare benefits available through Mr. Fountain's employment with Abington Memorial Hospital." Amended Complaint, exhibit C. Russo's complaint alleges that he has never received this benefit booklet. *fn1" Russo also wrote a letter to U.S. Healthcare, in September 1993, seeking, inter alia, information on Fountain's enrollment in U.S. Healthcare, information on the payment or denial of any medical bills, and "the benefits booklet in effect for Mr. Fountain's policy." Amended Complaint, exhibit F. U.S. Healthcare's response, in November 1993, did not provide a copy of the applicable benefits booklet; instead, it denied that Fountain had ever been properly enrolled in U.S. Healthcare, as his application had been filled out after his admission to the hospital.

 Russo then, in December 1993, filed a complaint in the Court of Common Pleas of Philadelphia County that made claims under Pennsylvania law against Abington Memorial Hospital and U.S. Healthcare. U.S. Healthcare filed a timely notice of removal, invoking this court's diversity jurisdiction. In a previous memorandum, dated March 29, 1995, this court (1) denied a motion to remand by Russo, and (2) granted a motion to dismiss by U.S. Healthcare, on the grounds that the state-law claims alleged in Russo's complaint were preempted by the Employee Retirement Income Security Act ("ERISA"). The court also granted Russo leave to submit an amended complaint, however, which Russo did.

 The amended complaint alleges four ERISA claims, two against Abington Healthcare Plan (rather than Abington Memorial Hospital, the previously named defendant) and two against U.S. Healthcare. Russo's first claim against Abington Healthcare Plan is grounded in the Plan's alleged failure to provide Russo with Fountain's benefit booklet, in violation of ERISA's requirement that the administrator of a plan provide plan information to beneficiaries upon request. *fn2" Under 29 U.S.C. § 1132(c)(1), a plan administrator can be liable to a beneficiary for up to $ 100 a day for such failures. *fn3" Russo's second claim against the Plan invokes ERISA to challenge the Plan's alleged role in Fountain's attempted enrollment, as well as the Plan's failure to pay benefits to Fountain under its own indemnity policy. *fn4"

 Russo makes broadly parallel claims against U.S. Healthcare. As he does against Abington Healthcare Plan, Russo makes a claim against U.S. Healthcare invoking 29 U.S.C. § 1132(c)(1) to challenge U.S. Healthcare's failure to provide plan information. Russo also asserts that U.S. Healthcare "has breached its fiduciary duty to Fountain by denying coverage for Fountain's AEMC [Albert Einstein Medical Center] bill" and "has violated ERISA by arbitrarily and capriciously administering the Plan and by denying coverage for Fountain's AEMC bill." Complaint, P 34, 35.

 Abington Healthcare Plan has also moved to dismiss Russo's two claims against it. The Plan asserts that Russo's claim that it failed to provide him with plan information is a "transparent attempt . . . to convert his discovery request under Rule 34 of the Federal Rules of Civil Procedure into an independent cause of action." Defendant Abington Healthcare Plan's Motion to Dismiss at 3-4. As to Russo's other claim against Abington Healthcare Plan, the Plan asserts that, if Russo's claim based upon U.S. Healthcare's denial of benefits to Fountain is dismissed, Russo's claim against ...


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