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Gillar v. Blue Cross

United States District Court, M.D. Pennsylvania

August 30, 2019




         Pending before the court are the defendant's motion for summary judgment (Doc. 12) and the plaintiffs' motion for summary judgment (Doc. 19). Based upon the court's review of the record in this action, the defendant's motion will be granted and the plaintiffs' motion will be denied.

         The plaintiffs filed this action pursuant to 29 U.S.C. §1132(a) to recover benefits under an ERISA regulated plan. In due course, the parties filed cross motions for summary judgment. Summary judgment is appropriate “if the pleadings, the discovery [including, depositions, answers to interrogatories, and admissions on file] and disclosure materials on file, and any affidavits show that there is no genuine issue as to any material fact and that the movant is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(c); see also Celotex Corp. v. Catrett, 477 U.S. 317, 322-23 (1986); Turner v. Schering-Plough Corp., 901 F.2d 335, 340 (3d Cir. 1990). A factual dispute is genuine if a reasonable jury could find for the non-moving party, and is material if it will affect the outcome of the trial under governing substantive law. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986); Aetna Cas. & Sur. Co. v. Ericksen, 903 F.Supp. 836, 838 (M.D. Pa. 1995). At the summary judgment stage, “the judge's function is not himself to weigh the evidence and determine the truth of the matter but to determine whether there is a genuine issue for trial.” Anderson, 477 U.S. at 249; see also Marino v. Indus. Crating Co., 358 F.3d 241, 247 (3d Cir. 2004) (a court may not weigh the evidence or make credibility determinations). Rather, the court must consider all evidence and inferences drawn therefrom in the light most favorable to the non-moving party. Andreoli v. Gates, 482 F.3d 641, 647 (3d Cir. 2007).

         To prevail on summary judgment, the moving party must affirmatively identify those portions of the record which demonstrate the absence of a genuine issue of material fact. Celotex, 477 U.S. at 323-24. The moving party can discharge the burden by showing that “on all the essential elements of its case on which it bears the burden of proof at trial, no reasonable jury could find for the non-moving party.” In re Bressman, 327 F.3d 229, 238 (3d Cir. 2003); see also Celotex, 477 U.S. at 325. If the moving party meets this initial burden, the non-moving party “must do more than simply show that there is some metaphysical doubt as to material facts, ” but must show sufficient evidence to support a jury verdict in its favor. Boyle v. County of Allegheny, 139 F.3d 386, 393 (3d Cir. 1998) (quoting Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586 (1986)). However, if the non-moving party “fails to make a showing sufficient to establish the existence of an element essential to [the non-movant's] case, and on which [the non-movant] will bear the burden of proof at trial, ” Rule 56 mandates the entry of summary judgment because such a failure “necessarily renders all other facts immaterial.” Celotex Corp., 477 U.S. at 322-23; Jakimas v. Hoffmann-La Roche, Inc., 485 F.3d 770, 777 (3d Cir. 2007).

         The summary judgment standard does not change when the parties have filed cross-motions for summary judgment. Appelmans v. City of Phila., 826 F.2d 214, 216 (3d Cir. 1987). When confronted with cross-motions for summary judgment, as in this case, “the court must rule on each party's motion on an individual and separate basis, determining, for each side, whether a judgment may be entered in accordance with the summary judgment standard.” Marciniak v. Prudential Financial Ins. Co. of America, 184 Fed.Appx. 266, 270 (3d Cir. 2006) (citations omitted) (not precedential). If review of cross-motions reveals no genuine issue of material fact, then judgment may be entered in favor of the party deserving of judgment in light of the law and undisputed facts. Iberia Foods Corp. v. Romeo, 150 F.3d 298, 302 (3d Cir. 1998) (citation omitted). See Nationwide Mut. Ins. Co. v. Roth, 2006 WL 3069721, at *3 (M.D. Pa. Oct. 26, 2006) aff'd, 252 Fed.Appx. 505 (3d Cir. 2007).

         In reviewing the parties' cross-motions for summary judgment, the following facts are undisputed.[1] The defendant provided a Master Group Contract to Ronald Gillar's employer, United Sporting Companies, which was effective January 1, 2017 (“Contract”). Pursuant to the Contract, Blue Cross administered the Plan of Benefits to employees of United Sporting Companies (“Plan”). The Plan provides coverage for medical benefits but in Section IV specifically delineates a list of benefits that are excluded from coverage under the Plan. One of these specific exclusions from the Plan is:

Any service (other than Substance Use Disorder Services), Medical Supplies, charges, or losses resulting from a Member being Legally Intoxicated or under the influence of any drug or other substance, or taking some action the purpose of which is to create a euphoric state or alter consciousness. The Member, or Member's representative, must provide any available test results showing blood alcohol and/or drug/substance levels upon request of the Corporation. If the Member refuses to provide these results, no benefits will be provided.

         The Plan defines “Legal Intoxication/Legally Intoxicated” as occurring when “the Member's blood alcohol level was at or in excess of the amount established under applicable state law to create a presumption and/or inference that the Member was under the influence of alcohol, when measured by law enforcement or medical personnel.”

         While the Plan provides that the employer, United Sporting Companies, is charged with the administration of the Plan, as indicated earlier, the Contract between United Sporting Companies and Blue Cross provides that Blue Cross has the final discretionary authority to determine whether plan participants are eligible for benefits. Specifically, the Contract provides:

5. Corporation Authority.
As claims fiduciary, the Corporation shall have the final discretionary authority to determine the eligibility for Covered Expenses and to construe the terms of the Plan represented by this Plan of Benefits. All decisions by the Corporation in this regard are conclusive and binding, and any judicial review of such a decision shall be conducted under the arbitrary and capricious standard of review with deference given to the Corporation's decision.

         Ronald Gillar was a Member covered by the Plan. According to Mr. Gillar's medical records, on or about June 9, 2017, he was found unresponsive lying face down in the middle of a road approximately 100 yards from an all-terrain vehicle (“ATV”). Having suffered significant injuries[2], the plaintiff was life-flighted to Danville Medical Center (“Danville”). Records show that the trauma transport reported a blood alcohol level of 130 milligrams per deciliter as of 23:48 on June 9, 2017, a level approximately 1.63 times the legal limit for a person to be deemed intoxicated and materially and appreciably impaired under either South Carolina law[3], as made applicable by the Plan, or Pennsylvania law[4], where the accident occurred. The plaintiff remained inpatient at Danville for 22 days.

         At some point in time, a claim for benefits was submitted to the defendant on Mr. Gillar's behalf. According to a Notice of Denial dated June 20, 2017, from Medical Management BCBSSC to Geisinger Medical Center, Mr. Gillar's contract did not cover his inpatient admission on June 10, 2017, because of the intoxication exclusion discussed previously. It was indicated that ...

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