United States District Court, E.D. Missouri, Eastern Division
MEMORANDUM AND ORDER
W. SIPPEL UNITED STATES DISTRICT JUDGE
sues defendant Gilster for a denial of benefits under the
Employee Retirement and Income Security Act (ERISA), 29
U.S.C. §1001 et seq. Plaintiff provides surgical
care to patients in Missouri and treated patient RC in the
amount of $60, 692.90. RC was a beneficiary of an ERISA
benefit plan (the Plan) sponsored and administered by
defendant. Before providing the medical care, plaintiff
alleges that it verified that RC was covered under the Plan.
Plaintiff then provided RC the medical care but defendant
ultimately failed to pay because RC and/or plaintiff failed
to provide requested documentation.
moves for summary judgment on the amended complaint for
plaintiff's failure to exhaust remedies. According to
defendant, plaintiff did not exhaust the Plan's internal
review procedures because it failed to timely appeal the
denial of benefits. Plaintiff responds that it did appeal the
denial of benefits and, alternatively, that it was excused
from doing so. Because plaintiff did not timely appeal the
denial of benefits and was required to do so, defendant is
entitled to judgment as a matter of law.
Governing Summary Judgment
standards for summary judgment are well settled. In ruling on
summary judgment, the Court views the facts and inferences
therefrom in the light most favorable to the nonmoving party.
Matsushita Elec. Indus. Co., Ltd. v. Zenith Radio
Corp., 475 U.S. 574, 587 (1986). The moving party has
the burden to establish both the absence of a genuine issue
of material fact and that it is entitled to judgment as a
matter of law. Fed.R.Civ.P. 56(a); Anderson v. Liberty
Lobby, Inc., 477 U.S. 242, 247 (1986); Celotex Corp.
v. Catrett, 477 U.S. 317, 322 (1986). Once the moving
party has met this burden, the nonmoving party may not rest
on the allegations in its pleadings but must set forth by
affidavit or other evidence specific facts showing that a
genuine issue of material fact exists. Fed.R.Civ.P. 56(c). At
the summary judgment stage, I will not weigh the evidence and
decide the truth of the matter, but rather I need only
determine if there is a genuine issue for trial.
Anderson, 477 U.S. at 249.
the husband of a Gilster employee. Defendant Gilster provides
medical benefits to its employees and their families under
the Plan. Defendant used Benefit Administrative Services, LLC
(BAS) to assist it with the administration of the Plan. At
the time of his surgery, RC was a participant in the Plan and
claims for benefits were handled for defendant by BAS. The
Plan does not provide benefits for work-related illness or
injuries covered by worker's compensation insurance. The
Plan requires participants to provide information if
requested to determine whether a claim is covered under the
performed spine surgery on RC in 2011. Plaintiff alleges that
it verified RC was eligible for benefits under the Plan
before performing surgery. BAS received Claim No. 24743249-01
with a service date of September 7, 2011, from plaintiff for
RC's surgery and, in response, sent plaintiff a letter on
October 19, 2011. This letter states that the processing of
the claim was delayed because BAS was awaiting
“accident details.” RC's wife was copied on
the letter. BAS also contacted plaintiff by telephone on
numerous occasions to advise that BAS still needed accident
information to process the claim. Neither plaintiff nor RC
ever provided the requested accident information.
sent an Explanation of Benefits (EOB) to plaintiff denying
the claim for RC on November 29, 2012. The EOB states the
entire requested amount of $60, 692.90 is
“ineligible” and under the section entitled
“Reason Code Description” it states that
“[w]e are closing our file at this time. There has been
no response to the requests for information that have been
sent multiple times.” Under the section entitled
“Messages” the EOB states that the file is closed
due to lack of response to requests for accident information
from the member. The EOB then provides the following the
If your claim is denied in part or whole, you may appeal the
determination by submitting written comments, documents,
records or other information relating to the claim, and, upon
request and free of charge, receive copies of all documents,
records and other information relevant to the claim. Your
appeal must be submitted in writing to the plan administrator
within 180 days after receipt of this notice. You will be
notified of the determination within 60 days after receipt of
your appeal. In addition, following the determination of your
appeal you have a right to bring a civil action under Section
502(a) of ERISA.
Plan requires all appeals be submitted in writing within 180
days following the initial denial of benefits and include
“all facts and theories supporting the claim for
benefits” and a “statement in clear and concise
terms of the reason or reasons for disagreement with the
handling of the claim.”
December 17, 2012, plaintiff's counsel sent BAS a letter
stating that “we have not been contacted by anyone
concerning RC. Therefore, this matter is not closed and my
client fully intends to pursue this matter.” Neither
BAS nor defendant received anything else from plaintiff
regarding RC's claim for benefits. Plaintiff subsequently
filed this lawsuit on July 29, 2015.
assignee of RC's claim to benefits under the Plan,
plaintiff “stands in the shoes of the assignor, and, if
the assignment is valid, has standing to assert whatever
rights the assignor possessed.” Grasso Enterprises,
LLC v. Express Scripts, Inc., 809 F.3d 1033, 1039 (8th
Cir. 2016) (internal quotation marks and citation omitted).
Thus, plaintiff is likewise required to exhaust an ERISA
plan's internal review procedures before bringing suit in
federal court unless one of the exceptions to exhaustion of
remedies applies. See id.; Brown v. J.B. Hunt
Transport Services, Inc., 586 F.3d 1079, 1084-85 (8th
Cir. 2009). Exhaustion of administrative remedies is a
threshold legal question that should be reviewed de novo.
See Kinkead v. Sw. Bell Corp. Sickness & Accident
Disability Benefit Plan, 111 F.3d 67, 68 (8th Cir.
1997). Here, the Plan requires all appeals be submitted in
writing within 180 days ...