2015 IL App (1st) 141690
Ill. App. Ct.2015Background
- Centro Medico Panamericano (an out‑patient surgical center) provided services to 16 patients for 21 procedures between 2007 and 2011 and called the Laborers’ Welfare Fund to verify coverage before each procedure.
- On verification calls plaintiff provided provider, patient, insurance, and procedure info; Fund representatives confirmed coverage and benefit levels but paid pursuant to the Plan’s “usual and customary” out‑of‑network allowance (based on Blue Cross Blue Shield data), resulting in partial payments totaling $35,491.05.
- Plaintiff’s internal verification logs sometimes referenced “usual and customary” or “Blue Cross Blue Shield”; plaintiff’s office manager believed coverage was 80% of billed charges and patients signed contracts promising to be personally liable for charges.
- In 2012 plaintiff sued (promissory estoppel), seeking ≈$98,000 for underpayments, alleging Fund representatives orally promised to pay a fixed percentage of billed charges regardless of usual‑and‑customary limits.
- Fund moved for summary judgment, submitting affidavits (claims director and expert) that calls routinely confirmed coverage but stated payments were subject to the Plan’s usual‑and‑customary limits; trial court granted summary judgment, finding no unambiguous promise and that the claim was ERISA‑preempted.
- Plaintiff appealed, arguing (1) an unambiguous oral promise was made, (2) ERISA did not preempt promissory estoppel, and (3) the trial court improperly considered hearsay and denied a motion to strike affidavit paragraphs under Ill. S. Ct. R. 191(a).
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Fund made an unambiguous oral promise to pay a fixed percentage of billed charges | Fund reps told Centro Medico they would pay a fixed percent of billed charges, so plaintiff reasonably relied | Calls merely confirmed coverage and benefit parameters; payments were governed by the written Plan and usual‑and‑customary limits | No unambiguous promise; summary judgment for Fund affirmed |
| Whether plaintiff reasonably relied to its detriment on any alleged promise | Plaintiff relied on reps’ oral statements and billed patients accordingly | No evidence of reliance beyond routine billing; call records reference usual‑and‑customary limits | Reliance not established as a matter of law because no unambiguous promise existed |
| Whether ERISA preempts plaintiff’s promissory estoppel claim | Plaintiff argues state promissory estoppel claim should survive | Fund argues dispute concerns ERISA‑governed benefit determinations and is preempted | Court affirmed on alternative ground (lack of promise) and did not reach preemption; trial court had found ERISA preemption |
| Whether the trial court abused its discretion by considering affidavits containing hearsay and denying Rule 191(a) strike motion | Affidavits contained inadmissible hearsay and contradicted deposition testimony; should be struck | Affiant (claims director) had personal knowledge of company procedures and call‑taking practices and could testify competently | No abuse of discretion: affidavits were sufficiently based on personal knowledge and admissible for summary judgment purposes |
Key Cases Cited
- Ioerger v. Halverson Construction Co., 232 Ill. 2d 196 (standards for summary judgment)
- Williams v. Manchester, 228 Ill. 2d 404 (summary judgment review and construction in favor of nonmovant)
- Weather‑Tite, Inc. v. University of St. Francis, 233 Ill. 2d 385 (de novo review of summary judgment)
- Newton Tractor Sales, Inc. v. Kubota Tractor Corp., 233 Ill. 2d 46 (elements of promissory estoppel)
- Robinson v. BDO Seidman, LLP, 367 Ill. App. 3d 366 (failure to show unambiguous promise defeats promissory estoppel)
- Chatham Surgicore, Ltd. v. Health Care Service Corp., 356 Ill. App. 3d 795 (promissory estoppel found where common intent existed that patients were covered)
- Central Illinois Light Co. v. Home Insurance Co., 213 Ill. 2d 141 (contract language given plain meaning if unambiguous)
- Thompson v. Gordon, 241 Ill. 2d 428 (extrinsic evidence for ambiguous contract language)
- Piser v. State Farm Mut. Automobile Insurance Co., 405 Ill. App. 3d 341 (Rule 191(a) affidavit sufficiency standard)