Centro Medico Panamericano, Ltd. v. Benefits Mgmt. Grp., Inc.
2016 IL App (1st) 151081 (Ill. App., 2016)Words & Phrases
EstoppelTrial Judge
Lynn EganAppellate Judge
HymanHolding
Outpatient surgical facility’s promissory estoppel claim against insurance benefits manager failed knowing that insurers do not pay based on unilaterally determined amounts.Fact Summary
Plaintiff Centro Medico Panamericano, Ltd., an Illinois corporation, owned an outpatient surgical facility (Fullerton Kimball Medical & Surgical Center) providing services for a patient referred by his physician. Centro Medico billed defendant Benefits Management Group, Inc., the third-party administrator for the patient’s insurer, over $85,000, expecting 60% reimbursement under the patient’s insurance plan. Benefits Management paid out a little more than $6000 after reducing the total billed by “usual, customary, and reasonable” limits and deducting the patient’s copay amount.
Centro Medico sued Benefits Management under a promissory estoppel theory for the difference between the amount billed and the amount paid, alleging that a Benefits Management’s representative promised Centro Medico that the services it intended to provide to the insured patient were covered, and after Centro Medico provided the services, Benefits Management “refused to provide the promised coverage.” Centro Medico further alleged that Benefits Management expressed the amount of benefits as “a percentage of Centro Medico’s billed charges.” Benefits Management moved for summary judgment under section 2-1005 of the Code of Civil Procedure (Code) (735 ILCS 5/2-1005 (West 2010)) on two bases: (i) the claim was preempted by the provisions in the Employee Retirement Income Security Act of 1974 (ERISA) (29 U.S.C. § 1144(a) (2006)) and (ii) Centro Medico failed to demonstrate a clear, unambiguous promise on which it reasonably and foreseeably relied. The trial court ruled that the cause was not preempted and granted summary judgment to Benefits Management based on the promissory estoppel theory.
We agree with the trial court that Centro Medico failed to establish the first element of a promissory estoppel claim, that Benefits Management made a clear and unambiguous promise regarding the reimbursement amount. The reimbursement rate of 60% for out-of-network coverage was unambiguous. The real crux of the issue is Benefits Management claims as the basis for calculating the reimbursement amount the “usual, customary, and reasonable” charges, while Centro Medico uses its total charges exceeding $85,000 as the basis for the calculation. This discrepancy demonstrates an ambiguity in the promise.
Additionally, we find as a matter of law that Centro Medico did not demonstrate its reliance on any alleged promise was reasonable. Thus, the trial court properly granted summary judgment. Because we affirm the trial court’s grant of summary judgment on the promissory estoppel claim, we need not address Centro Medico’s additional contention that federal preemption of the state claim under ERISA did not apply.