Lori D. Tribble v. State of Illinois

Before the Court is the motion for Summary Judgment of The Illinois Department of Central Management Services (“CMS or Respondent”) and Maureen T. O’Donnell, in her capacity as Acting Director of The Illinois Department of Central Management Services (“the Acting Director”) (or sometimes collectively “the Respondents”).

For the reasons stated below, the Court grants Summary Judgment in favor of the Respondent.

I. Summary Judgment Standard

Summary Judgment is proper if the pleadings, depositions, admissions, affidavits and other relevant matters on file show that there is no genuine issue of material fact and that the movant is entitled to judgment as a matter of law.

735 ILCS 5/2-1005(c); Freeman v. State, 55 Ill. Ct. Cl. 329, 334 (2003).

While a claimant need not prove his case at this stage, he must present sufficient evidentiary facts to support the elements of his claim or present some factual basis which would arguably entitle him to judgment.

Id. See also Kuwik v. Starmark Star Marketing & Admin. Inc., 232 Ill. App. 3d 8, 12 (2nd Dist. 1992); Barber-Coleman Co. v. A&K Midwest Insulation Co., 236 Ill. App. 3d 1065, 1071 (5th Dist. 1992).

II. Facts

Lori D. Tribble, (“Claimant”), brings this case in her capacity as Administrator with the Will Annexed of the Estate of Delores Keyes.

During her lifetime Dolores Keyes, a retired employee of the State of Illinois, was a member of the Quality Care Health Plan (“QCHP”) created pursuant to the terms of “State Employees Group Insurance Act of 1971” (“Act”) (5 ILCS 375/1 et. al.).

The Claimant seeks recovery of benefits for medical expenses incurred during Ms. Keyes’s lifetime which were purportedly covered under the QCHP created and administered pursuant to the Act.

[*186] Ms. Keyes retired in 1984 and was enrolled in the QCHP since July 1, 1988.

During

the relevant time frame, the administrator for QCHP was CIGNA.

In April 2004, Ms. Keyes fractured a hip, experienced other medical issues, and as a result, was hospitalized at Memorial Medical Center.

Ms. Keyes remained at Memorial Medical Center until April 14, 2004, whereupon she was transferred to the Lewis Memorial Christian Village.

The Claimant, Ms. Keyes’ daughter with power of attorney at the time, chose Lewis Memorial Christian Village to provide care for Ms. Keyes.

Ms. Keyes remained at Lewis Memorial Christian Village from April 14, 2004 until her death on March 19, 2006.

The Claimant is not seeking compensation for the medical bills incurred prior to July 9, 2004 since they were paid by Medicare.

The Claimant received documents from Medicare stating that the bills incurred after July 9, 2004 were being denied.

CIGNA representatives informed the Respondent that Medicare denied said medical bills because no skilled care was provided after July 9, 2004.

Ms. Keyes and/or the Claimant did not file an appeal of the Medicare denial or inquire why Medicare was denying benefits.

Ms. Keyes’ medical bills incurred after July 9, 2004 were then submitted to CIGNA, which denied coverage.

An appeal of the denial of coverage for the medical bills incurred during the period July 9, 2004 to October 19, 2004 was submitted to CIGNA.

On October 19, 2005, CIGNA

denied the appeal on the basis that the QCHP did not cover custodial care.

Based on the clinical information provided to CIGNA, it concluded that the services rendered after July 9, 2004 to Ms. Keyes were custodial in nature, with no ongoing skilled care services rendered after July 9, 2004.

After this denial, the Claimant did not ask any of Ms. Keyes’ physicians to contact CIGNA to discuss the services performed.

However, a second level appeal was filed with CIGNA.

On June 22, 2006, CIGNA denied the appeal for the same reasons given in the first appeal, i.e., that the services provided were custodial in nature and the treatment did not require a skilled nursing facility level of care.

The Claimant then made a request for an external independent review of the denial of coverage.

The external independent reviewer, CIMRO, also determined that the services provided to Ms. Keyes from July 9, 2004 onward were custodial in nature.

A request for a final Claim Determination was then submitted to the Department of Central Management Services (“CMS”), Group Insurance Division.

On September 1, 2006, after a review of all supporting documentation, the Group Insurance Division decided to uphold CIGNA’s determination and denied coverage for inpatient services rendered at Lewis Memorial Christian Village after July 9, 2004.

An appeal was then submitted to the Benefits Appeal Committee of CMS.

On

February 24, 2007 the Benefits Appeal Committee upheld the denial of coverage of services rendered to Ms. Keyes from July 9, 2004 onward.

The Claimant did not ask any of Ms. Keyes’ physicians to contact CMS to discuss the services performed.

On November 14, 2007, the Claimant filed suit seeking $94,837.87 for medical expenses incurred by Ms. Delores Keyes from July 9, 2004 through March 19, 2006, while she was living at the Lewis Memorial Christian Village in Springfield, Illinois.

III. Analysis

The decision sought to be reviewed by Claimant relating to Delores Keyes’s rights as a participant in QCHP is plainly a final “administrative decision” as defined by statute.

[*187] ILCS 5/3-101.1

Moreover, the “administrative decision” on appeal here resulted from a complete and thorough administrative process.

It is equally plain that the Court of Claims does not have jurisdiction to review administrative decisions where a statute provides that review must be in the Circuit Court or Appellate Court, 705 ILCS 505/8(a)(ii).

The State Employees Group Insurance Act, which created and governs the insurance plan at issue, expressly provides that any final order, decision or other determination of the Director of The Illinois Department of Central Management Services, including here those that relate to the rights of the Claimant as a participant in QCHP, “shall be subject to review in accordance with the provisions of the Administrative Review Law.” 5 ILCS 375/15(h).

The administrative Review law, in turn, mandates that “[J]urisdiction to review final administrative decisions is vested in the Circuit Courts…,” 735 ILCS 5/3-104.f

Claimant suggests that her claim is one founded in contract, as well as statute, and thus can be brought under the purview of this Court.

However, the dispute here did not involve the terms of any contract - only whether the care provided Ms. Keyes was “custodial” in nature or whether it was “skilled nursing.”

As such, the Claimant here is seeking review of an administrative decision.

Accordingly, the Court of Claims lacks jurisdiction to adjudicate the instant claims raised by the Claimant.

735 ILCS 505/8(a)(ii).

The Court also notes that Maureen T. O’Donnel, then Acting Director of CMS, was named as a Respondent for informational purposes only.

In this Court, the State is the ultimate and sole Respondent.

705 ILCS 505/8; Brustin, Ltd. V. State of Illinois, 50 Ill. Ct. Cl. 336 (1998); Alencastro v. State of Illinois, 54 Ill. Ct. Cl. 457 (2001).

IV. Conclusion

IT IS HEREBY ORDERED AND ADJUDGED that the Motion of the Respondent, The Illinois Department of Central Management Services, for Summary Judgment is hereby granted and the claim of Lori D. Tribble, in her capacity as Administrator with the Will Annexed of the Estate of Delores Keyes, is dismissed, with prejudice, each party to bear its own costs.

ORDER

Burns, J.

This cause comes on to be heard on the Claimant’s petition for rehearing following our opinion entered on September 22, 2011.

The Respondent filed a response.

The Claimant requests this Court to reconsider its decision to grant summary judgment to the Respondent due to this Court’s lack of subject matter jurisdiction over the claim.

The Claimant offers three reasons to support its argument for a re-hearing: 1) neither party had an opportunity to brief the issue of subject matter jurisdiction; 2) the Administrative review Law does not apply in this matter because the Director of Central Management Services (“CMS”) was not involved in any decision concerning the Claimant’s claim, and the Benefit Appeals Committee (the “BAC”) is not an administrative agency; and

“Administrative decision” or “decision” means any decision, order or determination of any administrative agency rendered in a particular case, which affects the legal rights, duties or privileges of parties and which terminates the proceedings before the administrative agency…” 735 ILCS 5/3-101.

[*188] 3) the Claimant’s case is a contract claim, and not one seeking review of an agency’s administrative decision.

We have carefully considered the Claimant’s petition and the record herein.

The

Claimant has raised no issue which was not previously considered by the Court.

First, the issue of subject matter jurisdiction can be raised at any time and by any means, including the court’s own motion. Conley v. State, 35 Ill.Ct.Cl. 275 (1982).

Indeed, the Court has an affirmative obligation to examine its subject matter jurisdiction. Id. The Claimant’s arguments regarding subject matter jurisdiction are incorporated in its petition, so there is no need for the parties to brief the issue.

Second, the Administrative Review Law defines an “administrative agency” as “a person, body of persons, group, officer, board, bureau, commission or department (other than a court or judge) of the State, or of any political subdivision of the State or municipal corporation in the State, having power under the law to make administrative decisions.” 735 ILCS 5/3-101.

An “administrative decision” is defined as “any decision, order or determination of any administrative agency rendered in a particular case, which affects the legal rights, duties or privileges of parties and which terminates the proceedings before the administrative agency.” Id. The Court finds that the BAC in this case would qualify as an administrative agency under this definition since it is a body of persons and/or a group of the State having the power under law to make administrative decisions.

Moreover, the BAC’s decision was a final decision that affected the legal rights, duties or privileges of the parties and terminated the proceedings before CMS.

As such, the Administrative Review Law applied to the Claimant’s cause of action.

Finally, this Court finds unavailing the Claimant’s argument that her claim here is one based on contract, not one seeking review of an administrative decision.

This Court

has previously determined that the State Employees Group Insurance Act does not create an enforceable contractual right on behalf of any employee seeking to enforce the Act. Gendel v. State, 38 Ill.Ct.Cl. 76, 81 (1985).

Therefore, the claimant here had no enforceable contract right under the Act and, thus, could not bring this claim under a contract theory.

Wherefore, we must affirm our prior opinion denying the Claimant’s claim and Claimant’s petition for rehearing is hereby DENIED.