Lead Opinion
Trustmark Life Insurance Company (“Trustmark”), formerly known as Benefit Trust Life Insurance Company, brought an action under the Employee Retirement Income Security Act, 29 U.S.C. § 1001, et seq. (“ERISA”), against the University of Chicago Hospitals & Health System (“UCH”) to recover payment made for breast cancer treatment of Grace Fuja, one of Trustmark’s insureds. On July 24, 1998, the district court entered final judgment in favor of Trustmark as to recovery and denied UCH’s state-law defenses as preempted under ERISA. UCH appealed and Trustmark cross-appealed the district court’s denial of attorney’s fees, costs, and prejudgment interest. We reverse.
Mrs. Fuja was a participant in an ERISA-governed employee welfare benefit plan (the “Plan”) sponsored by her employer Emsco Management Services, Inc. and insured by Benefit Trust Life Insurance Company, now known as Trustmark Life Insurance Company. As a breast cancer patient who had not responded to standard treatment, Mrs. Fuja sought high dose chemotherapy with autologous bone marrow transplant (“HDC/ABMT”) treatment. Trustmark denied precertification for HDC/ABMT treatment,claiming it was not “medically necessary” as defined under the Plan. Mrs. Fuja sought injunctive relief against Trustmark’s refusal to cover the HDC/ABMT treatment, and on December 22, 1992, the district court in that case enjoined Trustmark from denying coverage. See Fuja v. Benefit Trust Life Ins. Co.,
In addition, after receiving notice from Mrs. Fuja that she might not be able to pay her deductible and copayment obligations, UCH decided to waive Mrs. Fuja’s deductible and copay. Prior to entering the hospital for treatment on January 7, 1993, Mrs. Fuja signed an Admission and Out-Patient Agreement with an Authorization and Release of Benefits clause which stated that Mrs. Fuja would be financially responsible for the balance owed if her insurance did not pay the full amount due, which amount might include the costs of collection and/or reasonable attorney’s fees.
Less than a month after its unconditional statement of payment, on January 20, 1993, Trustmark filed its notice of appeal. During this period, Mrs. Fuja remained hospitalized until her death in March 1993. Shortly thereafter, Trustmark paid the sum of $362,232.97 to UCH for Mrs. Fuja’s treatment, again without specifying any conditions. Nearly a year later, on March 18, 1994, this court revеrsed the district court’s judgment, holding that Mrs. Fuja’s HDC/ABMT treatment did not fall within the parameters of “medically necessary” procedures as defined in the Plan policy because the treatment was “furnished in connection with medical ... research.” Fuja v. Benefit Trust Life Ins. Co.,
Trustmark subsequently filed an action in district court pursuing recovery of the amount paid to UCH for Mrs. Fuja’s HDC/ABMT treatment under § 502(a)(3).
As there are no disputes as to the issues of material facts, summary judgment is appropriate in this case. However, for the reasons set forth below, we reverse the judgment of the district court in favor of Trustmark. We affirm the denial of attorney’s fees, costs, and prejudgment interest.
II. ANALYSIS
A. Subject Matter Jurisdiction
Before reviewing the merits of Trustmark’s claim, we must first decide whether it was properly before the district court. ERISA regulates both employee pension plans and employee welfare benefit plans. 29 U.S.C. §§ 1002(3) & 1003(a). Participants, beneficiaries or fiduciaries of these plans (and the Secretary of Labor) may sue under ERISA. 29 U.S.C. § 1132(a). In Central States, Southeast and Southwest Areas Health & Welf. Fund v. Neurobehavioral Assocs.,
Like Neurobehavioral Assocs., UCH is a medical care provider who reсeived benefits from a welfare fund at the behest of a Plan participant, Mrs. Fuja, and is therefore recognized as a beneficiary. Mrs. Fuja sued the Plan in order to have those benefits paid. Fuja,
B. Common Law Defenses
Although we have determined that Trustmark’s action for recovery of ERISA benefits should be resolved in a federal forum, we must next determine the validity of UCH’s defenses based on common law principles. UCH argues the defenses of breach of contract and promissory es-toppel. We will review each claim in order to determine whether such common law principles are applicable under ERISA. We note, given the particular circumstances, thаt the law of the case doctrine does not foreclose consideration of these issues.
This circuit has already determined that all common law concepts are not automatically inapplicable in the ERISA context. Thomason v. Aetna Life Ins. Co., 9 F.8d 645, 647 (7th Cir.1993). In passing ERISA, Congress expected that “a federal common law of rights and obligations under ERISA-regulated plans would develop.” Pilot Life Ins. Co. v. Dedeaux,
1. Breach of Contract
UCH’s primary argument is that the letter from Trustmark promising payment constitutes a private contract which bypasses the Plan. After careful scrutiny of the district court record, we find that UCH has waived this argument as it was not raised at the district court level. See Moulton v. Vigo County,
This circuit refused to recognize a breach of contract claim in an ERISA setting. See Buckley Dement, Inc. v. Travelers Plan Administrator of Illinois, Inc.,
In its breach of contract argument, UCH characterizes itself as a third party who received payment after entering into an independent contract with the fiduciary. Neurobehavioral Assocs. refused to acknowledge this type of claim involving a medical care provider who had been directed by the insured as an assignee in receiving plan benefits.
UCH relies on The Meadows v. Employers Health Ins.,
UCH asserts that Trustmark made a promise to pay which created an independent contract. However, as stated in the letter from Trustmark’s executive, “Benefit Trust Life Insurance Company will comply with the court’s order and will cover charges for Mrs. Fuja’s ABMT treatment.”(emphasis added). UCH maintains that because Trustmark did not condition its payment pending an appeal, it created an independent contract. Although we agree that Trustmark did not place conditions on its payment, we do not believe the elements of a contract — offer, acceptance, and consideration — are present when one party is compelled by a court order to provide payment, as is the case here. In addition, even UCH concedes in its brief that Trustmark would want to appeal the district court’s order to pay for the treatment as it created an unfavorable precedent that would obligate it to pay for similar kinds of treatment in future cases under the same or similar ERISA plans. As noted in Neurobehavioral Assocs., this disruption of the Plan and the potential effect on the pension rights of others fundamentally involves ERISA.
2. Estoppel
This circuit has recognized that es-toppel principles can be applied to certain ERISA actions. Black v. TIC Inv. Corp.,
The factual question in this case involves the reasonable reliance of UCH in receiving payment for the medical services provided. In addition, the written confirmation from Trustmark satisfies the rule which requires modification of ERISA plans to be in writing. 29 U.S.C. § 1102(a)(1). UCH asserts that it would not have accepted the financial risk of providing HDC/ABMT treatment to Mrs. Fuja had Trustmark not provided a guarantee, but would have sought alternative means to ensure that it would receive payment for services before rendering them. We find that the claim is properly before us, although were emphasize the narrow scope of such claims. See Coker,
Summary judgment is reviewed de novo. Feldman v. American Memorial Life Ins. Co.,
UCH maintains that Trustmark is estopped from recovering the monies paid for Mrs. Fuja’s HDC/ABMT treatment because of Trustmark’s written (and oral) statements guaranteeing payment. Trust-mark clearly promised payment notwithstanding the fact that it was paid “under court order.” It is also logical that Trust-mark knew or should have known that its promise to pay would induce action on the part of UCH, particularly based on the “urgency” of Mrs. Fuja’s medical condition.
In determining whether an employer was entitled to a refund of pаyments in a restitution claim, the court in UIU Severance Pay Trust Fund v. United Steelworkers of America,
As discussed in Restatement of Restitution § 1, restitution is a device to avoid unjust enrichment. See also Central
In addition, we agree with the analysis in Rehabilitation Institute v. Group Adm’s,
C. Waiver of Copayments
Trustmark argues that UCH’s waiver of Mrs. Fuja’s copayment and deductible voids the insurance contract. See Kennedy v. Connecticut Gen. Life Ins. Co.,
D. Attorney’s Fees, Costs, and Prejudgment Interest
Trustmark maintains that it is entitled to attorney’s fees under § 502(g)(1) of ERISA. See 29 U.S.C. § 1132(g)(1). Section 502(g)(1) provides, “[i]n any action under this subchapter ... by a participant, beneficiary, or fiduciary, the court in its discretion may allow a reasonable attorney’s fee and costs of action to either party.” Our decision to reverse the district court’s judgment means that Trust-mark is no longer a prevailing party, and, therefore, is no longer entitled to an award of attorney’s fees. Even had Trustmark remained the prevailing party, we agree with the district court’s denial of attorney’s fees, costs, and prejudgment interest. We have chosen to review the merits of this issue because we conclude that each party should bear their own attorney’s fees and costs on appeal.
An award of attorney’s fees is reviewed for an abuse of discretion. Filipoivicz v. American Stores Benefit Plans Committee,
The general test for analyzing whether attorney’s fees should be awarded to a party in an ERISA case after it has attained “prevailing party” status is: “[W]as the losing party’s position substantially justified and taken in good faith, or was that party merely out to harass its opponent?” Quinn v. Blue Cross and Blue Shield Association,
Trustmark also acted in good faith. It was substantially justified in pursuing this action, given this court’s reversal of the injunction. Trustmark was not merely harassing UCH. As we noted earlier, this was an unusual case. Both parties had legitimate claims, with no clear winner or loser.
Prejudgment interest may be appropriate in ERISA cases. Lorenzen v. Employees Retirement Plan of Sperry & Hutchinson Co.,
UCH received Trustmark’s money as payment for medical services rendered. The district court found that UCH was not unjustly enriched by receiving payment for the treatments it provided to Mrs. Fuja. Nor did the fact that the appellate court determined the Plan did not cover the treatments indicate that UCH was guilty of wrongdoing or bad faith. We believe the district court acted within its discretion in denying Trustmark prejudgment interest. However, in this case, there is no evidence of bad faith on the part of either party.
For these reasons, we find that each party should bear its own attorney’s fees and costs.
III. CONCLUSION
We reverse the district court’s finding of summary judgment in favor of Trustmark and note that each party shall bear its own attorney’s fees and costs on appeal.
Notes
. Section 502(a)(3) states in relevant part:
a civil action may be brought—
by a participant, beneficiary or fiduciary (A) to enjoin any act or practice which violates any provision of this subchapter or the terms of the plan, or (B) to obtain other appropriate equitable relief (i) to redress such violations or (ii) to enforce any provisions of this subchapter or the terms of the plan. 29 U.S.C. § 1132(a)(3).
Federal courts have exclusive jurisdiction over actions brought pursuant to the abovе provision. 29 U.S.C. § 1132(e).
. In Connors v. Amax Coal Co., Inc.,
The Connors case is clearly distinguishable from the instant case. In Connors, the trustees of the plan were suing the employer.
Concurrence Opinion
concurring.
I write separately only to emphasize that I remain convinced that Trustmark was under no obligation to cover Grace Fuja’s request for bоne marrow treatment. See Fuja v. Benefit Trust Life Ins. Co.,
