Griffin v. Teamcare
909 F.3d 842 (7th Cir. 2018)Words & Phrases
ERISATrial Judge
Robert W. GettlemanAppellate Judge
Kanne and St. EveHolding
Insurer owed statutory ERISA penalties based on its failure to timely furnish plan documents upon plaintiff’s requestFact Summary
W.A. Griffin, M.D., is the assignee of her patient’s health plan, TeamCare, which the Board of Trustees of Central States, Southeast and Southwest Areas Health and Welfare Fund (collectively Central States) administers and the Employee Retirement Income Security Act (ERISA), 29 U.S.C.§§ 1001–1461, governs. Dr. Griffin sued Central States for underpayment and for statutory penalties based on its failure to furnish plan documents upon request. The district court dismissed her complaint. However, because we find that Dr. Griffin adequately alleged that she is eligible for additional benefits and statutory damages, we affirm the judgment only as to Count 2, vacate the judgment as to Counts 1 and 3, and remand Counts 1 and 3 for further proceedings.
Dr. Griffin, a dermatologist and surgeon, provided medical care to T.R., a participant in a Central States health plan. (Blue Cross Blue Shield is a third-party administrator of that plan.) Before receiving treatment, T.R. assigned to Dr. Griffin the rights under the plan to “pursue claims for benefits, statutory penalties, [and] breach of fiduciary duty ….” Dr. Griffin confirmed through a Central States representative that the plan would pay her for the treatment at the usual, reasonable, and customary rate, as section 11.09 of the plan document pro- vides.1 Dr. Griffin then treated T.R. and submitted a claim for $7,963, which she says is the applicable usual and customary rate, but Central States underpaid her by $5,014. Dr. Griffin challenged the benefits determination.