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Joseph Patrick v. Devon Health Services

November 18, 2011


The opinion of the court was delivered by: Surrick, J.


Presently before the Court are Plaintiff Joseph Patrick's Motion for Summary Judgment or Alternatively Motion for Bench Trial (ECF No. 17) and Defendant Devon Health Services, Inc.'s Motion for Summary Judgment (ECF No. 18). For the following reasons, Defendant's Motion will be granted, and Plaintiff's Motion will be denied.


A. Plaintiff's Single-Vehicle Automobile Accident

Plaintiff is a former employee of Defendant. (Patrick Dep. 6-10, Feb. 17, 2010, Def.'s Summ. J. Mot. Ex. B.) On November 28, 2007, while still employed by Defendant, Plaintiff was involved in a single-vehicle automobile accident on Route 23 in Schuylkill Township, Chester County, Pennsylvania. ( Id. at 10, 23.) At 4:30 p.m. on that date, Plaintiff left work at Defendant's King of Prussia office to meet co-workers for dinner and drinks at a restaurant called Sly Fox. ( Id. at 10-14.) Plaintiff drank four or five beers at Sly Fox. ( Id. at 16-17; see also Patrick Dep. 21, Aug. 8, 2008, Def.'s Summ. J. Mot. Ex. A.) *fn1 At 6:30 p.m. that evening, Plaintiff left Sly Fox to meet his then-girlfriend at Doc McGrogan's, a restaurant located in Phoenixville, Pennsylvania. (Patrick Dep. 21-22, Aug. 8, 2008; Patrick Dep. 17-18, Feb. 17, 2010.) *fn2 At 7:00 p.m. that evening, Plaintiff left Doc McGrogan's to go home. (Patrick Dep. 29, Aug. 8, 2008; Patrick Dep. 22, Feb. 17, 2010.) At 7:35 p.m., while driving eastbound on Route 23/Valley Forge Road, Plaintiff was involved in a one-vehicle accident outside of Valley Forge Park. (Patrick Dep. 29, Aug. 8, 2008; Patrick Dep. 23; Police Rep. 1, Def.'s Summ. J. Mot. Ex.

C.) Plaintiff estimates that the accident occurred a few minutes after he left Doc McGrogan's and one or two miles from that restaurant. (Patrick Dep. 29, Aug. 8, 2008; Patrick Dep. 23, Feb. 17, 2010.) Shortly after the accident, the police and an emergency ambulance crew were dispatched to the accident scene. (EMS Rep. 1, Def.'s Summ. J. Mot. Ex. D (dispatched at 7:36 p.m. and arriving at 7:36 p.m.); see also Police Rep. 1 (police officer arriving at 7:48 p.m.).)

Police Officer John R. Kane of the Schuylkill Township Police Department investigated the accident and completed a Police Crash Reporting Form ("Police Report"). The investigation revealed that Plaintiff's vehicle had left the roadway and hit a fixed object. It was dark at the time of the accident, and there were no streetlights. The road conditions were dry, and there were no adverse weather conditions. (Police Rep. 4.) Officer Kane ruled out environmental or roadway factors and possible vehicle failure as potential contributing factors to the accident. ( Id. ) He cited speed as a factor in causing the accident. ( Id .) Plaintiff's vehicle had been traveling in the eastbound lane at a high rate of speed when it failed to negotiate a curve. The vehicle left the roadway, traveled 226.5 feet and then hit a stone sign for Valley Forge National Park. ( Id. at 5.) Upon hitting the sign, the vehicle went airborne for 44 feet 11 inches, flipped over, end over end, and then came back onto the roadway. The final resting place of the vehicle was 64 feet 4 inches from its impact with the stone sign. ( Id. ) The Police Report indicated that the driver "[h]ad [b]een [d]rinking" and was charged. ( Id. at 2.) The front air bag had deployed, and Plaintiff had used his seatbelt and was not ejected from the vehicle. ( Id . at 3.) Officer Kane opined:

It is this Officer's belief that the driver had been under the influence of alcohol at the time of the accident and therefore was not capable of operating a vehicle in a safe manner. Also, the speed was a secondary factor in the accident for the reason that the vehicle basically destroyed the stone and steel sign and went airborne after hitting the sign. In conclusion, it was a combination of two factors that caused the accident. ( Id . at 5-6.) There were several witnesses to the accident who gave statements to Officer Kane. ( Id .) Medical records indicated that Plaintiff's BAC was 0.192. ( Id. at 2, 5-6.)

The EMS crew arrived at 7:36 p.m. and observed severe damage to Plaintiff's vehicle, including windshield and steering wheel damage, dashboard displacement and a damaged and pushed-in roof. (EMS Rep. 1.) The crew could not gain access to Plaintiff until the fire department arrived, stabilized the vehicle and gained access to Plaintiff. ( Id. ) The EMS Report reveals that the EMS crew found Plaintiff in the driver's seat but slumped over in the passenger's seat. ( Id .) Although Plaintiff answered when spoken to, he was "incoherent." ( Id . at 1, 3.) Plaintiff appeared lethargic and confused as to time, place and current events. However, he told the EMS crew that he had "had a lot to drink." ( Id . at 1.) He had slurred speech, blood coming from his nose, visible abrasion or bruising on his left mid-clavicular chest, deformity in his left femur, a large laceration to his right shin and abrasions to his right posterior hand. ( Id. ) He complained of bilateral leg pain. ( Id. ) The EMC crew observed ETOH odor. ( Id. *fn3 Plaintiff was transported from the accident scene to the Hospital of the University of Pennsylvania ("HUP") by helicopter at 8:01 p.m. that evening. ( Id.

At 8:21 p.m., Plaintiff arrived at the HUP, where he was treated for a broken left femur, pelvis and right hip. (HUP Rep. at 7, Def.'s Summ. J. Mot. Ex. E ; Patrick Dep. 29, Feb. 17, 2010.)Tests were conducted on Plaintiff. (HUP Rep. at 2-3.) While the tests showed negative results for drugs, such as amphetamines, opiates, barbiturates, benzodiazepines, THC and methadone, an ETOH test ordered on 8:59 p.m. that evening showed that Plaintiff's serum alcohol concentration was 192 mg/dL, which converts to a blood alcohol concentration ("BAC") of 0.16 percent. ( Id. at 3, 5; Cohn Rep. 3, Def.'s Summ. J. Mot. Ex. F.) The Initial Inpatient Admission/Consultation form of the HUP records ("HUP Records"), dated November 28 at 9:00 p.m., describes Plaintiff's history as follows: a "29 yo male unrestrained driver was involved in a MVA tonight --> intoxicated --> multiple extremity injuries." (HUP Rep. 6.) The "History of Present Illness/Injury" section of the form states that "[o]n physical exam the patient presents as conscious and alert and obvious[ly] intoxicated. The patient admits to drinking and states that he consumed a considerable amount of alcohol. Denies street drug use." ( Id. at 7.)

On November 29, 2007, Plaintiff was transferred to Temple University Hospital. ( Id. at 9.) Plaintiff remained at this hospital for two weeks, then was admitted to Bryn Mawr Rehabilitation Hospital, where he was treated for two weeks. (Patrick Dep. 29, Feb. 17, 2010.) Medical bills for the hospitalizations and further treatment of the injuries sustained in the accident total $871,693.37. (Moffa Dep. 92, Jan 14, 2010, Def.'s Summ. J. Mot. Ex. H & Ex. Moffa-5 (claims ledger).) *fn4

On December 18, 2007, Plaintiff was charged with driving under the influence in violation of 75 Pa. Cons. Stat. Ann. §§ 3802(A)(1), (A)(2), (B) and (C). (Pa. Ct. Comm. Pls. Dkt., Def.'s Summ. J. Mot. Ex. G.) Plaintiff was admitted to the Chester County Accelerated Rehabilitation Disposition ("ARD") program on April 1, 2008. (Id.)*fn5

B. The Devon Health Services, Inc. Employee Health Care PPO Plan

At the time of the accident, Plaintiff was covered by the Devon Health Services, Inc. Employee Health Care PPO Plan ("Plan") under a self-funded scheme. (Moffa Dep. 23.) *fn6 Under the Plan, claims for medical benefits are submitted to the Plan's third party administrator, UHY Advisors d/b/a/ Insurance Design Administrators ("IDA"). IDA then processes the claims to ensure that all documentation required for payment of the claim had been submitted and that the service was covered under the Plan. (Clark Dep. 8-10, Mar. 11, 2010, Pl.'s Summ. J. Mot., Ex. E, ECF No. 19.) IDA then re-prices the claim in accordance with an agreed-upon re-pricing schedule and submits the claim to Defendant for payment. ( Id. at 8-10, 52.) Defendant then pays the claim. (Moffa Dep. 30.) Defendant used United of Omaha Life Insurance Company ("Mutual of Omaha") as a stop-loss carrier for medical claims submitted by Defendant's employees exceeding $100,000. ( Id . at 25-26.) Under this arrangement, Defendant was obligated to pay the first $100,000 of medical benefits per individual claim, and Mutual of Omaha was obligated to make the remaining payments on the claim, up to $1,900,000, assuming the claim was covered. (Omaha Cert., Def.'s Summ. J. Mot., Ex. O.) Under the Plan, Defendant determines whether an employee is eligible for benefits and then pays those benefits out of its own pocket on a claim-by-claim basis. (Clark Dep. 9-10, 33-34, 54; Madonna Dep. 45, Pl.'s Summ. J. Mot., Ex. F.)

The Plan includes certain exclusions, including the following:

For all Medical Benefits shown in the Schedule of Benefits, a charge for the following is not covered:

48. Illegal Acts. Charges for services received as a result of Injury or Sickness caused by or contributed to by engaging in an illegal act or occupation; by committing or attempting to commit any crime, criminal act, assault or other felonious behavior; or by participating in a riot or public disturbance. This exclusion does not apply if the injury resulted from an act of domestic violence or a medical (including physical and mental health) condition. ("Illegality Exclusion") (Plan 22, 26, Def.'s Summ. J. Mot. Ex. J.)

The Plan provides the Plan Administrator with broad authority to interpret the terms of the Plan and to make determinations regarding issues concerning eligibility for benefits. Specifically, the Plan provides:

The Plan Administrator shall administer this Plan in accordance with its terms and establish its policies, interpretations, practices, and procedures. It is the express intent of the Plan that the Plan administrator shall have maximum legal discretionary authority to construe and interpret the terms and provisions of this Plan, to make determinations regarding issues which relate to eligibility for benefits, to decide disputes which may arise relative to the Plan Participants rights, and to decide questions of Plan interpretation and those of fact relating to this Plan. The decision of the Plan Administrator will be final and binding on all interested parties. (Id. at 17.)

If a claimant receives an adverse benefit determination, the claimant has 180 days following receipt of notification to appeal the decision. ( Id . at 6.) When appealing, the claimant can submit written documents, records and other information related to the claim. ( Id. ) The review of the decision takes into account all comments, documents, records and other information submitted by the claimant related to the claim. The Plan states that the review "will not afford deference to the initial adverse benefit determination and will be conducted by a fiduciary of this Plan who is neither the individual who made the adverse determination nor the subordinate of that individual." ( Id. at 7.)

C. Plaintiff's Submission of Claim

IDA processed Plaintiff's medical claim and forwarded to the Plan Administrator a copy of the Police Report and medical HUP Records for Plaintiff. (Moffa Dep. 121-22.) Based on the Police Report and records indicating that Plaintiff was intoxicated, the Plan Administrator denied Plaintiff's claim pursuant to the Illegality Exclusion because she determined that Plaintiff had engaged in an illegal act and that this act caused or contributed to the ...

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