Conway v. Benefis Health System, Inc.
2013 MT 73
| Mont. | 2013Background
- Conway sues Benefis in state court alleging breach of contract, third-party beneficiary breach, and related claims, including fraud and MT Consumer Protection Act violations.
- PPA between TRICARE's network administrator BCBS and Benefis governs TRICARE payments and sets the reimbursement framework; TRICARE is secondary payer to Kemper medical payments coverage.
- Benefis billed TRICARE and Kemper; TRICARE paid $1,866.29 (later accepted as payment in full under the PPA) and Kemper paid $1,866.29; the PPA limits payments to TRICARE rates for Covered Services, with TRICARE beneficiaries responsible for copays.
- Conway’s medical expenses totaled $2,073.65; TRICARE paid the reduced amount, and Conway seeks the excess $1,203.55 from Kemper under medical payments coverage.
- District Court converted Conway’s Rule 12(c) motion to a Rule 56 summary judgment motion after Benefis attached the PPA to its response; court granted summary judgment to Conway on breach of contract, finding Conway an intended third-party beneficiary of the PPA.
- Benefis sought supervisory control; this Court denied relief, and later the District Court certified a class; final judgment followed on the conversion and partial summary judgment, which Benefis appeals.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the court properly converted the 12(c) motion to summary judgment | Conway contends conversion was proper under applicable rules. | Benefis argues notice and opportunity to present material were lacking. | Correct: district court did not err in converting |
| Whether summary judgment for Conway on breach of contract was proper | Conway contends Benefis breached the PPA by taking more than TRICARE rate. | Benefis asserts Conway is not a proper beneficiary and there were damages/entitlements issues. | In error: summary judgment for Conway reversed |
| Whether class certification was proper | Conway argues class should be certified under Rule 23 for similar excess-payments claims. | Benefis challenges typicality and manageability of the class. | Not reached due to reversal on damages issue |
Key Cases Cited
- Rafanelli v. Dale, 292 Mont. 277 (Mont. 1998) (treatment of outside-pleadings materials when converting Rule 12(c) motions)
- Bretz v. Ayers, 756 P.2d 1117 (Mont. 1988) (fair notice to consider extra-pleadings materials supports conversion to summary judgment)
- Firelight Meadows, LLC v. 3 Rivers Telephone Coop., Inc., 344 Mont. 117 (Mont. 2008) (pleading attachments can be part of pleadings when incorporated by reference)
- Ritter v. Bill Barrett Corp., 210 P.3d 688 (Mont. 2009) (Rule 12(c) standard and summary judgment framework)
- Nelson v. Barlow, 179 P.3d 529 (Mont. 2008) (standard for reviewing summary judgment and related motions)
- Newbury v. State Farm Fire & Cas. Ins. Co., 184 P.3d 1021 (Mont. 2008) (medical payments coverage pays medical expenses; windfalls not allowed)