Opinion
No. 5-768 / 05-0246
Filed November 23, 2005
Appeal from the Iowa District Court for Johnson County, Douglas S. Russell, Judge.
Mary Eggiman appeals from district court order granting summary judgment and dismissing her claim for benefits under a medical insurance policy. AFFIRMED.
Wallace L. Taylor, Cedar Rapids, for appellant.
Brian J. Fagan and Larry G. Gutz of Moyer Bergman, P.L.C., Cedar Rapids, for appellees.
Heard by Sackett, C.J., and Vogel and Eisenhauer, JJ.
Mary Eggiman appeals from the district court order granting summary judgment on her claim for benefits under a medical insurance policy issued through her husband's employer, R.H. Hummer Jr., Inc. (Hummer), and administered by Self-Insured Services Co. (SISCO). We affirm.
Background Facts and Proceedings.
Eggiman suffers from clinical obesity and became interested in having gastric bypass surgery to address that problem. After contacting the Bariatric Treatment Center in 2001, she was determined to be an appropriate candidate. Eggiman's insurance policy through Hummer provided the following conditions for the coverage of such a procedure:
26. Charges for services in connection with surgical treatment of morbid obesity will be considered Eligible Expenses, subject to the following conditions:
a. A second concurring opinion is required prior to the surgical procedure; and
b. Pre-authorization is required.
Coverage is subject to the following guidelines:
a. Body weight must be at least 200% of the optimal weight.
"Pre-authorization" which is thus required under this provision is not defined either in this specific provision or elsewhere in the policy. However, the plan contains the separate concept of "pre-certification," which appears to be generally required for all hospital admissions. The detailed process for receiving pre-certification is fleshed out in almost one full page of the policy. The confusion between the terms "pre-authorization" and "pre-certification" is the underlying basis of Eggiman's claim.
On April 23, 2001, a health insurance review specialist hired by Eggiman's physician sought, by letter to SISCO, pre-authorization for the procedure. She informed SISCO that Eggiman weighed 283.8 pounds and was thus 132.8 pounds overweight. On May 14, 2001, that health insurance review specialist was informed by SISCO that Eggiman had not met all the criteria for the payment of benefits.
On June 5, 2001, Eggiman personally received a letter from HealthCorp. Inc., the plan's managed care company, informing her that "hospitalization cannot be certified due to" insufficient information. A copy of the letter was sent to SISCO, the plan administrator/claims processor, as both companies are under the parent company umbrella of Cottingham Butler. Then, on June 15, 2001, Eggiman received another letter from HealthCorp. informing her that she had been "pre-certified" for a "gastric bypass for obesity." The letter, however, also specifically noted that the pre-certification "does not guarantee payment." In a separate June 15, 2001 letter from a medical claims supervisor for SISCO to the health insurance review specialist, "pre-authorization" was again denied. There is no indication this letter was sent to Eggiman. In the letter SISCO specifically noted that according to the previous letter which sought authorization, Eggiman was only 188% of her ideal weight and thus not sufficiently obese to merit coverage. Finally, in a July 24, 2001 letter from HealthCorp. to Eggiman, she was personally notified that her hospital stay had been pre-certified.
Assuming she had received the approval for payment of the necessary procedure, Eggiman went forward with the gastric bypass surgery on July 30, 2001 and underwent a second, corrective surgery on August 14, 2001. In a subsequent letter dated September 11, 2001, SISCO informed Eggiman that it was denying her claim for benefits. The letter noted that she had not met the requirement that she weigh at least 200% of her optimal weight. Eggiman then caused her physician to inform SISCO that she had indeed been at least 200% of her optimal weight, however, coverage was still denied.
Eggiman later filed an action against Hummer and SISCO seeking payment of medical expenses related to the gastric bypass surgery. Hummer and SISCO filed a motion for summary judgment, which the district court granted following a hearing. The court first concluded no genuine issue of material fact remained as to her coverage under the terms of the plan. It therefore found as a matter of law that it was proper to deny benefits based on Eggiman's failure to obtain pre-authorization. The court further found that SISCO held no fiduciary responsibility to Eggiman, as contemplated under the Employment Retirement Income and Security Act (ERISA), and that it therefore could not be found liable for any allegedly misleading statements it made to Eggiman. Eggiman appeals.
Scope of Review.
Our review of a summary judgment ruling is for correction of errors at law. Iowa R. App. P. 6.4; Bailey v. Batchelder, 576 N.W.2d 334, 337 (Iowa 1998). Summary judgment is appropriate when the moving party shows no genuine issue of material fact exists, and it is entitled to judgment as a matter of law. Bennett v. MC No. 619, Inc., 586 N.W.2d 512, 516 (Iowa 1998).
Error Preservation.
In its summary judgment ruling, the district court analyzed the requisites for recovery under the plan. It found that while the plan generally requires "pre-certification" as a requisite for coverage, it also specifically requires "pre-authorization" for coverage for surgical treatment of morbid obesity. The court concluded there were no factual disputes with regard to the approval Eggiman was required to obtain, and that it was therefore proper for the defendant to deny benefits based on Eggiman's failure to obtain pre-authorization.
It is apparent that Eggiman does not specifically contest this conclusion on appeal. Rather, in her reply brief, Eggiman concedes that her argument is based on the position that she has a valid ERISA claim because of the defendants' misleading statements which erroneously caused her to believe she would be covered under the medical plan. It is undisputed that ERISA provides a cause of action for a fiduciary's misrepresentation of health care coverage. See Berlin v. Michigan Bell Tel. Co., 858 F.2d 1154, 1163 (6th Cir. 1988). However, we find it significant that the district court made no findings or conclusions with regard to whether the defendants' actions and statements were misleading or whether Eggiman was, in fact, misled.
In fact, at oral argument, Eggiman's counsel argued that "misrepresentation is the essence of the case."
The question thus arises whether Eggiman has preserved this claim for appellate review. We conclude she has not. First, we look to Eggiman's petition. In that pleading, her only cause of action was that the defendants "denied medical and health care benefits to the plaintiff to which she was entitled." We next move to the summary judgment order in which, as we noted above, the court did not discuss in any fashion a claim that Eggiman was entitled to benefits by virtue of any misleading statements or misrepresentations. The court specifically held that "there are no genuine issues of material fact as to interpretation of the terms of the plan regarding the pre-certification and pre-authorization processes." Finally, Eggiman did not make a motion pursuant to Iowa Rule of Civil Procedure 1.904(2) alerting the court to its failure to address such a claim.
It is a fundamental doctrine of appellate review that issues must ordinarily be both raised and decided by the district court before we will decide them on appeal. Metz v. Amoco Oil Co., 581 N.W.2d 597, 600 (Iowa 1998) ("issues must be presented to and passed upon by the district court"). Here, the district court never addressed, or even recognized as an issue, that claim which Eggiman now forwards on appeal and which she characterizes as the very essence of her case. Furthermore, when a district court fails to rule on an issue properly raised by a party, the party who raised the issue must file a motion requesting a ruling in order to preserve error for appeal. Benavides v. J.C. Penney Life Ins. Co., 539 N.W.2d 352, 356 (Iowa 1995). No such post-ruling motion was made here. Under these circumstances we conclude this contention is not preserved for appellate review. We therefore affirm the court's order granting summary judgment. AFFIRMED.
We find it unnecessary to address Eggiman's second contention on appeal — that the court erred in failing to conclude that SISCO is a fiduciary under the plan. It appears the reason this was decided by the district court is because only a fiducially can be liable for misrepresentations under ERISA. See Ince v. Aetna Health Mgmt., Inc., 173 F.3d 672, 674 (8th Cir. 1999). Having concluded that Eggiman has not preserved error as to whether she was misled, addressing whether SISCO is a fiduciary would serve no purpose.
Eisenhauer, J., concurs; Sackett, C.J., concurs specially.
While I am compelled to concur with the majority decision, I do not like the result.