Professional Documents
Culture Documents
08-16875-CC
Plaintiffs-Appellees,
v.
Defendants-Appellants.
Page
Table of Contents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
Table of Citations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii
Certificate of Compliance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Certificate of Service.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
i
Table of Citations
Federal Cases
Administrative Comm. (Wal-Mart) v. Shank, 500 F.3d 834 (8th Cir. 2007).. . . . 10
Benefit Recovery, Inc. v. Donelon, 521 F.3d 326 (5th Cir. 2008). . . . . . . . . . . . . . 8
Cutting v. Jerome Foods, Inc., 993 F.2d 1293 (7th Cir. 1993).. . . . . . . . . . . . 3-5, 8
Great-West Life & Ann. Ins. Co. v. Knudson, 534 U.S. 204 (2001). . . . . . . . . . 5-8
Marshall v. Employers Health Ins. Co., No. 96-6063, 1997 U.S. App.
Sereboff v. Mid Atlantic Medical Services, Inc., 547 U.S. 356 (2006). . . . . . 1, 5-8
Federal Statutes
29 U.S.C. § 1144(b)(2)(A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
29 U.S.C. § 1182(b).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ii
Federal Regulations
iii
Argument and Citations of Authority
The parties are in basic agreement about the state of the law up to a point.
The parties agree that Sereboff and other controlling cases hold that a group health
out of which reimbursement is due and the portion due. Zurich Brief at 8.1 The
parties agree that the provisions of Zurich’s plan seek such relief (Zurich Brief at
9-10), with the exception that the definition of the amount of the recovery as the
“reasonable value” of the medical services does not define a specific fund.
O’Hara Opening Brief at 49-50.2 The parties agree that the remaining question is
U.S.C. § 1132(a)(3). Zurich Brief at 10. At this point, the parties disagree about
the significance of the stipulated fact that Keith O’Hara was not made whole by
1
The Court should, of course, refrain from confusing a necessary condition
for recovery (pleading a case that sounds in equity, to avoid dismissal at the
pleading stage under a Rule 12(b)(6) motion) with a sufficient condition for a final
decree on the merits: proving that the relief is in fact “appropriate equitable relief.”
2
Contrary to Zurich’s suggestion at 10, O’Hara’s agreement to set aside the
money claimed by Zurich does not constitute O’Hara’s agreement that this sum
was the “reasonable value” of the services rendered, which is the controlling
standard as defined by the plan.
1
receipt of settlement funds in this case.3 Doc. 51 at 5(¶16). This Court must
ing traditional equitable limitations on any awardable relief, and preventing Zurich
Cagle v. Bruner, 112 F.3d 1510, 1520-1522 (11th Cir. 1997), is the definitive
priate equitable relief” in 29 U.S.C. § 1132(a)(3), though Cagle does not contain
once for the point that the plaintiff cited it as a jurisdictional basis in the com-
3
Since Zurich stipulated to this fact, the Court should disregard the suggest-
ion in Zurich’s Brief at 10 that this is an open question, that O’Hara’s position
consists merely “in his view” that he was not made whole for all his injuries.
4
In O’Hara’s Opening Brief at 44, the undersigned overlooked this refer-
ence in the “procedural history” section of the opinion and erroneously stated that
the case made no citation to 29 U.S.C. § 1132(a)(3). It remains true, however, that
no part of the opinion turned on an interpretation of 29 U.S.C. § 1132(a)(3).
2
Zurich offers nothing at all, except perhaps the law of inertia.
In his Opening Brief at 42-44, O’Hara showed that there are two types of
make-whole rules and that Cagle involved a make-whole rule of the first type.
Make-whole rules of the first type address the meaning and application of plan
terms when a reimbursement provision would conflict with the overall purpose of
the plan that the insurer will bear the risk of the individual’s medical expenses.
Since this type of rule is a mere gap-filler, a rule that decides which of the two
purposes controls in case of a conflict between them, it is not needed when the
drafter provides an explicit term that resolves the conflict. However, O’Hara also
showed that there are make-whole rules of the second type, which are substantive
The make-whole cases that Zurich cites confirm O’Hara’s argument that
Cagle and similar decisions relate to make-whole rules of the first type rather than
Inc., 993 F.2d 1293 (7th Cir. 1993), does not cite 29 U.S.C. § 1132(a)(3), does not
contain the word “appropriate,” and contains the word “equitable” only in connec-
5
The Court should not succumb to Zurich’s implicit argument that, by
referring to the make-whole rule, there is only one possible make-whole rule.
3
tion with a peripheral discussion of equitable estoppel. Instead, the case turned on
arose from a recognition that if the reimbursement term was to be enforced, the
individual “would derive no benefit in fact from the plan,” and that it would be
“misleading” to say that the plan had paid her medical benefits. Id. The Cuttings
did not ask the court to enforce the limitation of 29 U.S.C. § 1132(a)(3); they
asked it to adopt a principle of federal common law. Id. at 1296. “[T]he so-called
universal rule of subrogation for which the Cuttings contend is a rule of interpre-
tation.” Id. at 1297 (emphasis added). “Because, as the Cuttings concede, the
language in the plan.” Id. at 1298-1299 (emphasis added). O’Hara does not make
interpretation.”
Plan, 64 F.3d 1389 (9th Cir. 1995), the court does not cite 29 U.S.C. § 1132(a)(3),
and therefore it does not discuss, let alone apply, the term “appropriate equitable
federal common law, quoting Cutting’s description of the rule as “a rule of inter-
pretation . . . [and] a gap filler.” Id. at 1394 (emphasis added), quoting Cutting,
4
The same is true of Marshall v. Employers Health Ins. Co., No. 96-6063,
1997 U.S. App. LEXIS 36769 (6th Cir. 1997), which does not cite 29 U.S.C.
§ 1132(a)(3) and which does not discuss or apply the term “appropriate equitable
relief.” The court follows Barnes and Cagle in holding that “Courts which have
applied the make-whole rule have emphasized that it is a rule of interpretation and
functions merely as a default rule” (id. at *11, emphasis added), and it quotes
Cutting for the observation that this version of the rule is “just a principle of
These cases remain viable on the interpretation of plan language that con-
flicts with the purpose of the plan to pay for the insured’s medical expenses. They
are, however, fundamentally irrelevant to the scope and limits of relief under 29
U.S.C. § 1132(a)(3). For after Cagle, after Cutting, after Barnes, and after Mar-
shall, the Supreme Court instructed the lower courts on how to construe 29 U.S.C.
§ 1132(a)(3), and how to apply it in this very context. Zurich has no qualms about
asking this Court to follow Knudson and Sereboff where they hold that Zurich’s
simply asks the Court now to follow the directions given in Knudson and Sereboff
about the scope and limits of “appropriate equitable relief” within 29 U.S.C. §
1132(a)(3). Both cases direct the courts to “consult[], as we have done, standard
current works such as Dobbs, Palmer, Corbin, and the Restatements, which make
5
the answer clear.” Knudson, 534 U.S. at 217 (footnote omitted) (emphasis added).
In Sereboff v. Mid Atl. Med. Servs., Inc., 547 U.S. 356, 364-366 (2006), the
issues on the scope and limits of equitable relief. As shown in O’Hara’s opening
brief at 25-29, the “standard current works” show that equitable principles within a
few pages of those cited by the Supreme Court authorize courts to refuse equitable
Zurich has simply failed to argue how, under the Supreme Court’s analysis,
the phrase “appropriate equitable relief” could be construed to allow the parties to
contract away any equitable principle and to enforce inequitable results automati-
cally. In view of the cases cited at 12-14 of O’Hara’s opening brief, in which the
Supreme Court has held that equitable relief authorized by federal statutes for the
equitable discretion, Zurich’s position would be the most perverse and anomalous
result imaginable.
Zurich argues that O’Hara’s argument proves too much, because if a make-
6
whole rule is implicit in 29 U.S.C. § 1132(a)(3), there would be no reason for
allow. Zurich Brief at 13. This argument is anachronistic. The Supreme Court’s
guidance in Knudson and Sereboff occurred after Cagle. The Cagle Court cannot
be faulted for failing to anticipate those developments and failing to apply them
sua sponte. The net result of the Knudson-Sereboff cases is that plans cannot
“contract out” of the Congressional limitation that they obtain only “appropriate
equitable relief,” and O’Hara simply asks this Court to enforce it.
Zurich argues that a make-whole rule would “leave plans, plan participants,
and the courts with no objective standards to use” in deciding whether the indivi-
dual is made whole. Zurich Brief at 13, n.2. On the contrary, district courts
routinely apply those standards in trying tort claims in diversity cases. The
amount that would compensate the individual for all losses in a tort case is a
question of fact under rules for damages that have not changed in decades. When
the trier of fact decides that amount, it is then easy to add (a) the amount paid by
the plan to (b) the amount recovered by the individual to determine whether that
sum is greater than (c) the verdict that establishes full compensation.
Zurich misstates O’Hara’s argument at 13-14. O’Hara does not contend that
federal courts are bound to apply state court decisions on equity. O’Hara agrees
that federal law preempts state law on this issue, at least if the plan is not insured.
7
See Benefit Recovery, Inc. v. Donelon, 521 F.3d 326 (5th Cir. 2008) (state law
empts Zurich’s attempts to contract out of traditional principles of equity, and the
Zurich notes that O’Hara cites no cases holding that 29 U.S.C. § 1132(a)(3)
anachronistic. O’Hara has made no secret of his position that this is the first time
that the issue has been properly and adequately raised. Sereboff notes that the
issue was not properly raised in the courts below, and that it would not decide it
there. 547 U.S. at 368, n.2. Before that decision in 2006, the judicial opinions
were in turmoil over the meaning of the Knudson decision and whether it preclud-
29 U.S.C. § 1132(a)(3) is now ripe for its first real consideration. (The cases that
Zurich cites in connection with this argument were addressed in Part 1 above.)
provide health benefit plans (Zurich Brief at 15-16) was addressed in part in
8
[V]ague notions of a statute’s “basic purpose” are nonetheless
inadequate to overcome the words of its text regarding the specific
issue under consideration. [Cit.] This is especially true with legis-
lation such as ERISA, an enormously complex and detailed statute
that resolved innumerable disputes between powerful competing
interests – not all in favor of potential plaintiffs.
Mertens v. Hewitt Assocs., 508 U.S. 248, 261-262 (1993). Congress has resolved
but if it is inequitable, Zurich may not recover. This limitation is implied into the
plan by operation of law, even if it is not expressed there. Zurich, in other words,
commitment to pay the part of actual medical expenses above 22% of the pro-
jected level of medical costs, but Zurich’s contention that such recoveries reduce
other employees’ costs is nonsensical. Zurich Brief at 16-18. The stipulated facts
show that Zurich plan participants will pay approximately 22% of the projected
costs whether or not Mr. O’Hara is made to give up his compensation for future
earnings and his being maimed. Doc. 51 at 3-4 (¶¶ 10-11). Zurich does not
explain how its receipt of reimbursement recoveries from O’Hara will affect future
9
expected costs, which are a function of (a) the medical services that Zurich
employees will need and (b) the charges for those services by medical care
providers. Instead, as stipulated (id. at ¶ 11), the money simply reduces the
amount that Zurich agreed to provide for employee benefits, which means that it is
pure profit for Zurich, as numerous courts have concluded. See cases collected in
Zurich’s argument here, like the Eighth Circuit’s Shank decision that it
cites, is based on no facts, just dogma, that “all other plan members would bear the
cost in the form of higher premiums.” If there were a factual basis for this dogma,
Zurich could have produced it. Zurich would not have stipulated that it sets the
target contribution for employees at 22% of the anticipated cost of the benefits it
will provide. Doc. 51 at 3, ¶ 10. Zurich certainly would not have stipulated that
the Plan,” id. at ¶ 11, since it quotes the Eighth Circuit for crediting these recover-
ies to the account of other employees. It would not have stipulated to the illustra-
tion that other employees would still pay 22% of the projected benefits, the tort
victim would pay 50% (in that illustration), and Zurich would pay 28% (if the ex-
10
3. Zurich’s argument shows that the reimbursement provision is
discriminatory, in violation of 29 U.S.C. § 1182.
This Part replies to the arguments at 18-21 of Zurich’s brief on the question
provision, 29 U.S.C. § 1182. O’Hara notes that Zurich does not answer the part of
O’Hara’s argument showing that equity alone, without HIPAA, requires equal
treatment among plan beneficiaries and that, accordingly, the reimbursement pro-
Assume that two of Zurich’s employees are driving home after work
in the same car, and due to the driver’s negligence, both sustain
medical bills for both. The passenger sues the driver and recovers for
pain and suffering, lost future wages, and medical expenses from the
Zurich first asserts the stipulated fact that all participants paid the same
11
premiums for the same level of insurance coverage. Zurich Brief at 18. However,
29 U.S.C. § 1182(b) is not limited to requiring the same premium. It provides that
a plan “may not require any individual (as a condition of enrollment or continued
enrollment under the plan) to pay a premium or contribution which is greater than
the hypothetical, the passenger pays a much higher contribution to the plan than
the driver. These are “contributions,” since as Zurich has stipulated, “subrogation
recoveries reduce the amount that Zurich is required to contribute to the plan.”
Doc. 51 at 3 (¶ 11).
Zurich next argues that its reimbursement features apply equally to all parti-
cipants and beneficiaries. Zurich Brief at 18. Zurich cites nothing in the record to
support this assertion, but assuming that the assertion is true, the equal application
of the reimbursement feature does not prevent, but rather guarantees, unequal
benefits for plan participants or unequal contributions from them, either of which
violates HIPAA. In the hypothetical, it guarantees that the driver receives the full
payment of medical care benefits that he is entitled to under Zurich’s plan, but it
6
Zurich refers to O’Hara’s benefits as “advances” or payments “advanced”
at 1, 2, 7, 12 of its Brief.
12
guarantees that the passenger contributes not only the same premiums that the
driver pays, but also the recovery of future wages that he will never receive.
requires that “benefits must be ‘uniformly available’ to all ‘similarly situated indi-
viduals,’” Zurich Brief at 19, like the driver and passenger in the hypothetical, and
like O’Hara in real life. O’Hara further agrees with Zurich’s statement that “by
their terms, these statutory and regulatory provisions prohibit plans from singling
out similarly situated people by imposing unequal treatment,” id., like the passen-
In view of this, Zurich’s argument that this case is “not about plan ‘premi-
ums’ or ‘contributions’,” but about its right to exercise its reimbursement provi-
sion (Zurich Brief at 19-20), misses the point of 29 U.S.C. § 1182. 29 U.S.C.
Contrary to Zurich’s claim that it “is not asking Mr. O’Hara to pay addition-
al amounts towards his coverage out of his family’s general assets” (Zurich Brief
at 20), because Zurich has stipulated that O’Hara has not been made whole, Zurich
is precisely asking O’Hara to pay additional amounts out of his family’s general
13
assets. His “family’s general assets” included his bodily integrity and his earning
capacity before this wreck, and they include the compensation for his loss of both
after this wreck. If Zurich recovers in this case, O’Hara will be giving the cash
equivalent of his bodily integrity and earning capacity to Zurich in order to allow
Zurich to reduce Zurich’s liability to its employees. Yes, Zurich is indeed asking
Likewise, Zurich is wrong to claim that “Mr. O’Hara cannot credibly argue
that his wife’s premiums or contributions were higher than what any other similar-
ly situated covered individuals paid.” Id. The premiums were the same, but the
equivalent of her spouse’s bodily integrity and earning capacity would have to be
contributed to the plan, for the specific purpose of reducing Zurich’s contribution
to the plan, and this would exceed by far the contributions required of other Zurich
employees.
repay benefits that other plan participants do not have to repay, because he re-
ceived money due to being severely injured, receiving health care, and having a
particular claims experience, all of which are defined as “health status-related fac-
tors.” In the hypothetical, the plan discriminates between the claims experience of
the driver and passenger by deciding that the driver’s claims experience warrants
14
payment of benefits, but finding the passenger’s claims experience to be too costly
to do more than advance benefits that must be repaid. HIPAA’s requirement that
would apply equally to the similarly situated driver and passenger in the hypothe-
tical, but the driver gets his medical expenses paid in full, whereas the passenger
capped payments for both the driver and passenger at, say, $10,000, or if it pro-
vided that both the driver and passenger equally repay their medical expenses from
their future earnings, or if it required both the driver and the passenger to pay a
higher deductible or co-pay. But if it applies to cause the driver and passenger to
have different benefits under the plan, as Zurich’s reimbursement provision does,
violates HIPAA.
15
Conclusion
For the reasons given in O’Hara’s Opening Brief and above, the judgment
below should be reversed. Judgment should be entered for Keith O’Hara because
it is stipulated that he was not made whole and because “appropriate equitable
relief” requires that he be made whole before Zurich may obtain reimbursement,
and because relief for Zurich would impose a disproportionate and discriminatory
burden on O’Hara.
Respectfully Submitted,
_______________________________
Charles M. Cork, III
Ga. Bar No. 187915
830 Mulberry Street, Suite 203
Macon, Georgia 31201
Telephone: (478) 742-0204
Telecopy: (478) 742-0190
Attorney for Defendants-Appellants Keith O’Hara and Ross & Pines, LLC
16
Certificate of Compliance
Pursuant to FRAP 32(a)(7)(c), I hereby certify that this brief complied with
point Times New Roman font, a proportionately spaced font, and it contains 3,785
17
Certificate of Service
served this REPLY BRIEF OF APPELLANTS by first class mail, postage prepaid, to
_______________________________
Charles M. Cork, III
18