Anderson v. Blue Cross and Blue Shield et al
Filing
27
Memorandum Opinion and Order granting 18 MOTION for Summary Judgment of Blue Cross and Blue Shield. Signed by District Judge Tom S. Lee on 10/17/13 (LWE)
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF MISSISSIPPI
JACKSON DIVISION
SILAS J. ANDERSON
PLAINTIFF
VS.
CIVIL ACTION NO. 3:13CV402TSL-JMR
BLUE CROSS AND BLUE SHIELD,
THE UNIVERSITY OF MISSISSIPPI MEDICAL CENTER,
AND SOUTHERN FARM BUREAU CASUALTY
INSURANCE COMPANY
DEFENDANTS
MEMORANDUM OPINION AND ORDER
This cause is before the court on the motion of defendant
Blue Cross Blue Shield of Mississippi, A Mutual Insurance Company
(Blue Cross) for summary judgment pursuant to Rule 56 of the
Federal Rules of Civil Procedure.
Plaintiff Silas J. Anderson has
responded to the motion and the court, having considered the
memoranda of authorities, together with attachments, submitted by
the parties, concludes that the motion should be granted.
Plaintiff Anderson filed suit in state court alleging that
“Blue Cross & Blue Shield and/or Southern Farm Bureau Casualty
Insurance Company issued to Silas J. Anderson a policy of
insurance”; that “[o]n or about February 25, 2012, a vehicle
accident occurred in which Plaintiff was injured and ... required
medical attention”; that “the motorist driving the vehicle that
caused the accident did not have vehicular liability insurance”;
and that “an actual controversy exists as to whether Plaintiff is
entitled to insurance coverage for the injuries he sustained in
the ... vehicle accident.”
He seeks a declaratory judgment that
“the Defendant is liable to pay and indemnify plaintiff for all of
the medical expenses incurred or to be accrued by Plaintiff with
respect to any injuries incurred during the ... accident.”
Southern Farm Bureau removed the case to this court on the basis
of federal question jurisdiction under 28 U.S.C. § 1331, since the
insurance policy to which plaintiff’s complaint refers is a selffunded health benefit plan sponsored by Southern Farm Bureau for
its employees (including Anderson’s wife, Rosie Anderson), which
is governed by the Employee Retirement Income Security Act
(ERISA), 29 U.S.C. § 1001 et seq.
ERISA provides participants or beneficiaries a method of
civil enforcement “to recover benefits due to him under the terms
of his plan,” 29 U.S.C. § 1132(a)(1)(B), but does not identify who
is a proper defendant in such a case.
Blue Cross contends in its
motion for summary judgment that it is not a proper party to this
action as it is not the sponsor or insurer of the subject plan but
rather is only the claims administrator.
Citing Riley v. Blue
Cross & Blue Shield of Mississippi, No. 3:09CV674HTW–LRA, 2011 WL
2946716 (S.D. Miss. July 21, 2011), Blue Cross asserts that a
claims administrator is not a proper defendant in an action for
the wrongful denial of benefits under an ERISA plan, and that the
only proper defendant is the plan itself.
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As noted by Blue Cross,
the court in Riley declared, “The law is settled and clear in the
Fifth Circuit and its District Courts that Blue Cross, as a third
party administrator only, is not a proper party to an ERISA action
seeking plan benefits.”
2011 WL 2946716, at 3 (emphasis added)
(citing Sikes v. Life Ins. Co. of North America, 2009 WL 4351474
(W.D. La. 2009)).
The Riley court quoted from Sikes as follows:
“[D]istrict courts within the Fifth Circuit have
consistently held that the only proper defendant in an
ERISA enforcement action is the plan itself, regardless
of control over the plan.” Johnson v. Hartford Life and
Accident Ins. Co., No. H–09–56, 2009 WL 540959, *3 (S.D.
Tex. March 4, 2009) (citing Lee v. Tyco Elec. Power
Sys., Inc., No. 3:04–CV–2260–D, 2006 WL 1722569, *6–7
(N.D. Tex. June 20, 2006); Metro Life Ins. Co. v.
Palmer, 238 F. Supp. 2d 831, 835 (E.D. Tex. 2002);
Murphy v. Wal–Mart Assoc. Group Health Plan, 928 F.
Supp. 700, 709 (E.D. Tex. 1996)).... [No] case in the
Fifth Circuit has held that a third-party plan
administrator that is not a plan's sponsor is a proper
defendant.
2011 WL 2946716, at 3 (quoting Sikes, at 2).
The court in
Johnson, which was cited in Sikes, acknowledged that some circuits
have “permitted suits against administrators, in addition to the
plan as an entity, ... based on the administrator's control over
the plan and fiduciary status[,]” Johnson, 2009 WL 540959, at 3,
but it determined that the Fifth Circuit was not among those
circuits, id.
In fact, however, the Fifth Circuit more recently
held in Firman v. Life Insurance Co. of North America that Life
Insurance Company of North America (LINA), while not the ERISA
Plan sponsor or administrator under the plan but rather the
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designated claims administrator, was a proper defendant in a suit
for the wrongful denial of benefits where the policies at issue
“conferred upon LINA ‘full discretionary authority to administer
and interpret’ [the] policies.”
684 F.3d 533, 535 (5th Cir. 2012).
This holding is in keeping with previous Fifth Circuit cases which
implicitly recognized that a claims administrator is a proper
defendant in an action under § 1132(a)(1)(B) where “[t]he claims
administrator ‘has full discretion and authority to construe and
interpret all terms and provisions which relate to the amount of,
or eligibility for, benefits under the Plan’[,]” even where the
Plan “also states that ‘the Employer has the responsibility for
making final determinations regarding eligibility for coverage.’”
Chandler v. Hartford Life, 178 Fed. Appx. 365, 369 (5th Cir. 2006).
Nevertheless, while a claims administrator that had “full
discretion and authority” to administer and interpret the plan
would be a proper defendant, the evidence adduced by Blue Cross
shows that it is not in that category.1
1
The plan grants Blue
The court notes that plaintiff did not identify Blue
Cross as the claims administrator in his complaint but rather
alleged only that “Blue Cross and/or Southern Farm Bureau ... is
the insurer....” Notwithstanding that documents submitted by Blue
Cross plainly show that Blue Cross is not the insurer, plaintiff
asserts in his response that he had and has “reason to believe”
that Blue Cross is the insurer because it sent him an Accident
Questionnaire following the accident and it paid two of his
medical bills. However, in taking these actions, Blue Cross was
obviously acting in its capacity as claims administrator for
Southern Farm Bureau.
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Cross, as claims administrator, “the authority to interpret the
Plan for purposes of initial processing and payment of claims and
the denial of Medical Necessity of hospital or medical treatment.”
It goes on to state,
However, the Claims Administrator does not underwrite or
insure the participants in the Plan and the Claims
Administrator is subject to the direction of the Group
with respect to any questions regarding eligibility for
claims payment, the amount of claims payment and any
controversy involving employees and dependents with
respect to the Plan. The Group, with respect to the
control and management of the operation and
administration of the Plan, including the denial of
claims for benefits, and with respect to the review of
denied claims, shall have the discretionary authority to
interpret the Plan, including the determination of
whether and to what extent Covered Persons are eligible
for coverage and Benefits under the Plan.
In his response to the motion, plaintiff does not address this
Plan’s explicit limitation on Blue Cross’s discretion with respect
to determination of eligibility for coverage and the denial of
claims, and instead, he asserts that since the parties have yet to
conduct discovery to determine whether the defendant is solely the
claims administrator, “Defendant’s Motion for Summary judgment
should be denied or held in abeyance until discovery is complete.”
The Fifth Circuit has made clear that
In order to obtain a Rule 56(d) continuance to respond
to a summary judgment motion, the nonmovant must
“present specific facts explaining his inability to make
a substantive response ... and specifically
demonstrating how postponement of a ruling on the motion
will enable him, by discovery or other means, to rebut
the movant's showing of the absence of a genuine issue
of fact.” Washington v. Allstate Ins. Co., 901 F.2d
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1281, 1285 (5th Cir. 1990) (internal quotations and
citations omitted) (construing former Rule 56(f)); see
also Fed. R. Civ. P. 56(d).
Shelton v. Lemons, 486 Fed. Appx. 395, 396-397 (5th Cir. 2012).
Here, as in Shelton, plaintiff “has not provided this court with
any specific facts that suggest additional time for discovery
would have enabled him to locate information that would ...
successfully rebut[] [Blue Cross’s] summary judgment motion, [and
therefore] his ... Rule 56(d) [motion] fails.”
Id.
Based on the foregoing, it is ordered that Blue Cross’s
motion for summary judgment is granted.
SO ORDERED this 17th
day of October, 2013.
/s/Tom S. Lee
UNITED STATES DISTRICT JUDGE
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