Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Abdilnour v. Blue Cross of Idaho Health Service Inc.

United States District Court, D. Idaho

May 4, 2018

LOUIE ABDILNOUR, Plaintiff,
v.
BLUE CROSS OF IDAHO HEALTH SERVICE INC., an Idaho insurance corporation, Defendant.

          MEMORANDUM DECISION AND ORDER

          B. LYNN WINMILL, CHIEF U.S. DISTRICT COURT JUDGE

         INTRODUCTION

         Pending before the Court is Defendant's Motion to Dismiss for failure to exhaust administrative remedies (Dkt. 7). The motion is fully briefed and the Court heard oral argument on April 23, 2018. For the reasons explained below, the Court will deny the motion.

         BACKGROUND

         Plaintiff Louie Abdilnour was an employee with Albertson's LLC, and a participant in the Albertson's LLC Health and Welfare Plan (the “Plan”). Compl. ¶ 4, Dkt. 1. Defendant Blue Cross of Idaho Health Service, Inc. (“BCI”) is an Idaho insurance corporation, which acts as the claims administrator and insurer of the Albertson's LLC Health and Welfare Plan. Id. ¶ 5.

         On or about April 3, 2015, Plaintiff was transported by air ambulance service from Mercy Medical Center in Williston, North Dakota to Sanford Hospital in Bismarck, North Dakota. Id. ¶ 11-17. On or about May 7, 2015, Plaintiff was again transported by air ambulance service from Mercy Medical Center to Sanford Hospital. Id. ¶ 18-22. Valley Med Flight (“VMF”) provided the air transport on both occasions. Id. ¶ 16-17, 22. Also on May 7, 2015, VMF obtained written authorization from Plaintiff to submit claims for payment for services provided, and to appeal payment denials or other adverse decisions on his behalf. Pl.'s Resp. Ex. 1, Dkt. 10-2.

         VMF submitted a claim to BCI for $43, 648.00 for the April 3 air ambulance transportation, and BCI processed the claim on May 4, 2015. Def's Br. at 3, Dkt. 7-1. BCI sent Plaintiff a check for $10, 747, 76 and an Explanation of Benefits (“EOB”) stating that VMF's charges exceeded the allowable amount for the service. Id. at 4. VMF submitted a claim to BCI for $43, 092.00 for the May 7 air transport, and BCI processed the claim on June 15, 2015. Id. at 5. BCI sent Plaintiff a check for $10, 670.72 and an EOB stating that VMF's charges exceeded the allowable amount for the service. Id.

         On July 24, 2015, a representative from VMF sent a letter to the Blue Cross of Idaho Appeals and Grievance Coordinator, carbon copied to the Plaintiff. Cook Decl. Ex. A, Dkt 7-2. The letter includes Plaintiff's name and member number, and the date of service, the billed amount, and the claim number for the May 7 claim. Id. The letter states “we are APPEALING your decision. We disagree and dispute your payment of $10, 670.72.” Id. The letter states the alleged grounds for the appeal - that the transport was medically necessary, and constituted “pre-emergent services” under the ACA - and that “your member should not be penalized for receiving the necessary medical services . . . .” Id. The letter further states “As a non-contracted provider, we are under no obligation to accept a reduced payment and will not honor any discounted allowable, leaving your member responsible for any unpaid balance.” Id. The letter appears to only appeal the payment for the second air ambulance transport of May 7, 2015. See Id. It does not reference the April 3 transport or payment. See id.

         After receiving the letter, BCI forwarded it on to Blue Cross Blue Shield of North Dakota “because the local Blue Plan is responsible for communications with their local providers rendering services and submitting claims in their state.” Cook Decl. ¶ 8, Dkt. 7-2. On August 7, 2015, BCBS of North Dakota sent a letter to VMF, stating “The requested claim was reviewed by our reimbursement team. The claim did process correctly according to the current Blue Cross Blue Shield of North Dakota fee schedule.” Sorenson Decl. Ex. 2, Dkt. 10-4. The letter included Mr. Abdilnour's name, plan number, and a claim number. Id. On October 20, 2015, BCBS of North Dakota sent a second letter to VMF, stating “Your request for additional reimbursement was previously reviewed on August 07, 2015 by our reimbursement team and determined to have been paid correctly according to the current Blue Cross Blue Shield fee schedule providers. No. additional review will be made.” Sorenson Decl. Ex. 3, Dkt. 10-4. The letter again included Mr. Abdilnour's name, plan number, and a claim number. Id.

         On March 28, 2016, BCI received a request from Plaintiff's counsel for records and information related to Mr. Abdilnour's claims for the air transport service rendered on April 3 and May 7, 2015. Overman Decl. Ex. F, Dkt. 7-5. Before proceeding, BCI asked Plaintiff to complete an “Appointment of Authorized Representative Form.” Def.'s Br. at 6, Dkt. 7-1. On May 10, 2016, BCI provided Plaintiff's Counsel with some of the requested information. Overman Decl. Ex. G, Dkt. 7-4.

         On February 23, 2017, Plaintiff's Counsel notified BCI that he was representing Plaintiff in “continuing his appeal of BCI's claim determinations” related to the April 3, and May 4, 2015 air transport services. Overman Decl. Ex. H, Dkt. 7-4. The letter stated that “the benefits determinations were appealed on July 24, 2015” and that “BCBSND issued notices concerning these appeals on August 7, 2015 and October 20, 205, and denied/failed to resolve further” Mr. Abdilnour's claims. Id. On April 19, 2017, BCI denied Plaintiff's appeal as untimely. Overman Decl. Ex. I, Dkt. 7-4. BCI did not address, or even acknowledge the July 24 letter in their denial. See id.

         Plaintiff filed his Complaint in this case on October 3, 2017. Compl., Dkt. 1. The Complaint alleges that BCI breached the terms of its employee welfare benefit plan, in violation of the Employee Retirement Income Security Act of 1974 (“ERISA) § 502, 29 U.S.C. § 1132(a)(1)(B) by failing to provide full coverage for the costs of his medical transport by air ambulance on April 3 and May 7, 2015. Id. The Defendants have filed this motion to dismiss on the grounds that Plaintiff failed to exhaust his administrative remedies by timely appealing the claim determination, as required by the Plan. Def.'s Br., Dkt 7-1.

         The Plan states:

You have the right to appeal any denied claim. Your appeal must be filed with the Claims Administrator in writing, within 180 days after you receive the written notice of the reduction or denial . . . . If you have followed these procedures and you still do not agree with the Claims Administrator's decision about your claim, you can file suit in federal court. These claims and appeals procedures ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.