848 F. Supp. 2d 805
W.D. Mich.2012Background
- ERISA-regulated plan seeks restitution for medical benefits paid for thirteen student-dependents injured in athletic activities; GTL provided excess medical coverage; First Agency sold GTL policies and administered claims; ERISA plan COB clauses conflict with GTL’s COB; court treats motions as summary judgment; court grants plaintiff partial summary judgment on liability and denies defendant motions; court holds ERISA COB priority over GTL COB and GTL primary for the student injuries.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| COB priority between ERISA Plan and GTL policy | Plan COB has priority under Thorn Apple Valley. | GTL COB should apply or be reconciled; plan disavowal not explicit. | Plan COB priority; GTL primary under Plan terms. |
| Whether Article 5.01(a) applies to GTL as Other Plan | Article 5.01(a) favors primary coverage by non-Other Plan. | GTL lacks specific risk coverage; Article 5.01(a) not applicable. | Article 5.01(a) applies; GTL primary. |
| Whether Article 5.01(c) governs dependents versus direct GTL coverage | Student-dependents covered under GTL as dependents. | Participants/dependents distinction unclear; GTL not primary by 5.01(c). | 5.01(c) allocates primary responsibility to GTL. |
| Statute of limitations on ERISA § 502(a)(3) claims | Plan ten-year limitation governs; GTL contract limits ambiguous. | GTL contractual limits apply. | ERISA-era limitations favored; GTL limits not controlling. |
| Dismissal of First Agency | First Agency administers claims and denial; must remain. | No impact on relief; could be dismissed. | First Agency remains a proper defendant. |
Key Cases Cited
- Thorn Apple Valley, Inc. v. Auto Owners Ins. Co., 31 F.3d 371 (6th Cir. 1994) (COB policy terms must give full effect to ERISA plan)
- Great-West Life & Annuity Ins. Co. v. Allstate Ins. Co., 202 F.3d 897 (6th Cir. 2000) (plain meaning of COB provisions; ERISA contract interpretation)
- Newby Int'l, Inc. v. Nautilus Ins. Co., 112 Fed.Appx. 397 (6th Cir. 2004) (ambiguities construed against insurer; ERISA claims favored)
- Auto Owners Ins. Co. v. Thorn Apple Valley, Inc., 31 F.3d 371 (6th Cir. 1994) (ERISA COB priority and national uniformity)