Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-5_04-cv-03125/USCOURTS-cand-5_04-cv-03125-4/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 28:1331 Fed. Question

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ORDER, page 1

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

SAN JOSE DIVISION

HOBIE H. TRIVITTE, Administrator of the

Estate of Eleanor Ann Trivitte,

Plaintiff,

v.

HEALTHCOMP, INC., et al.,

Defendant.

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Case No.: C04-3125 PVT

FINDINGS OF FACT AND CONCLUSIONS OF

LAW; AND JUDGMENT

I. FINDINGS OF FACT AND CONCLUSIONS OF LAW

This matter came on for court trial before Magistrate Judge Patricia V. Trumbull on May 1,

2006. Based on the evidence and argument presented at trial, the court makes the following 

findings of fact and conclusions of law, and based thereon enters judgment in favor of Defendants.

A. FINDINGS OF FACT

1. Eleanor Ann Trivitte was a participant of the Northern California Golf Association

Employee Health Care Plan (the “Plan”).

2. The Plan is a self-funded employee welfare benefit plan subject to the provisions of

the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C.

§§ 1132, et seq.

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ORDER, page 2

3. The Northern California Golf Association is the “Plan Administrator” for the Plan.

4. HealthComp Inc. is the licensed Third Party Claims Administrator for the Plan.

5. The Plan confers discretionary authority to the Plan Administrator to construe and

interpret the terms of the Plan, to make determinations regarding issues which relate

to eligibility for benefits, to decide disputes that may arise relative to a Plan

Participant’s rights, and to decide questions of Plan interpretation and those of fact

relating to the Plan.

6. Ms. Trivitte died following a vehicle accident that occurred on September 2, 2002.

7. Prior to her death, Ms. Trivitte received medical treatment for the injuries she

sustained in the accident.

8. Ms. Trivitte’s son, Hobie Trivitte, retained Vincent Kilduff to represent him in

connection with a wrongful death action on his own behalf, and also to handle his

mother’s estate.

9. Letters of Administration were issued authorizing Hobie Trivitte (“Trivitte”) to

administer his mother’s estate.

10. At some point, Trivitte asserted a wrongful death claim–solely on his own behalf–

against third parties Ronald Landiesel and Vanessa Sandoval. Mr. Kilduff and

Trivitte failed to assert any claims against the third parties on behalf of the Estate of

Eleanor Ann Trivitte (the “Estate”).

11. Trivitte settled his claims against Ronald Landiesel and Vanessa Sandoval, and their

insurer, for $50,000.00.

12. At some point, Mr. Kilduff presented a claim for underinsured motorist insurance

benefits to Amco, Ms. Trivitte’s automobile insurer.

13. On or about April 2, 2003, Mr. Kilduff was advised that Ms. Trivitte was a

participant in the Plan.

14. On April 16, 2003, Mr. Kilduff sent a letter to HealthComp asking them to pay

certain medical expenses incurred for treatment of Ms. Trivitte’s injuries before her

death, and attaching copies of statements from the providers. This letter constituted

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1 The Plan states that “[a] request for Plan benefits will be considered a claim for Plan

benefits . . . .” (Plan at p. 67.) Although the Plan generally requires claims to be submitted within 45

days after the charges are incurred, there is an exception if it is not reasonably possible to submit the

claim within that time and the claim is submitted within one year from the date the charges are incurred.

In the present case, it was not reasonably possible for Ms. Trivitte to submit the claim within 45 days

because she died the day after the accident, and was hospitalized for that day. The attorney for the Estate

testified that he first learned of Ms. Trivitte’s coverage under the Plan on April 2, 2003. Thus he

arguably could not have earlier submitted the claim. He submitted the claim just two weeks later on

April 16, 2003. And at trial, Defendants did not contend the April 16, 2003 letter was not a timely

claim, nor offer any testimony or evidence that would support such a contention. 

2 For reasons discussed below, whether or not Mr. Kilduff understood Ms. Tovar was

asking him to obtain the forms is immaterial to the court’s decision.

ORDER, page 3

a timely claim by the Estate for benefits under the Plan.1

15. On April 28, 2003, Linda Tovar, a Claim Team Lead at HealthComp, called the

hospital about getting the UB 92 and HCFA 1500 forms, which she needed in order

to process the Estate’s claim. She was informed that they could not give her the

information because the matter was in litigation.

16. Ms. Tovar then called Mr. Kilduff. She advised him she would need UB 92 and

HCFA 1500 forms in order to process the claim, because there was not enough

information on either billing to process the claim. She told him she had tried to get

the forms, but couldn’t. She informed him that either he or whoever was in

litigation would need to contact the providers and ask for the forms so HealthComp

could send the forms to the PPO Network for pricing, and they in turn would tell

HealthComp the allowable amount.

17. Mr. Kilduff either did not understand that Ms. Tovar was asking him to obtain the

forms for HealthComp, or if he did understand at the time he either forgot to follow

through, or else chose to ignore the request.2

18. At some point in time, the Estate received $5,000 from Ms. Trivitte’s car insurance.

19. There was no contact between the Estate and HealthComp between April 28, 2003

and August 16, 2003.

20. On August 16, 2003, Mr. Kilduff again wrote to HealthComp asking that they pay

the medical expenses. 

21. When Ms. Tovar received Mr. Kilduff’s August 16, 2003 letter, she had not

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3 At trial, the Estate offered testimony from Mr. Kilduff regarding a purported

“agreement” between himself and the insurer to the effect that the naming of the Estate on the release

and the check was in error. The Estate also sought to enter into evidence a letter Mr. Kilduff

purportedly wrote to the insurer confirming such an agreement. The court sustained hearsay

objections to both Mr. Kilduff’s testimony and the letter. The Estate argued that the testimony and

the letter were not hearsay because they constituted the operative terms of an agreement and showed

Mr. Kilduff’s state of mind. Mr. Kilduff’s state of mind is not relevant here. Further, the words of

an agreement are only an exception to the hearsay prohibition where the words uttered are not offered

to prove the truth of the matter asserted. See FED.R.EVID. 801(c) Advisory Note (“If the significance

of an offered statement lies solely in the fact that it was made, no issue is raised as to the truth of

anything asserted, and the statement is not hearsay.”) Here, the words uttered were offered to prove

the truth of the matter asserted, i.e. that the insurer had named the Estate on the release and the check

“by mistake.” Thus, Mr. Kilduff’s testimony and the letter are inadmissible hearsay. This ruling

furthers the purposes of the hearsay rule because no one from the insurance company was available

for Defendants to cross-examine.

4

 The excerpts he sent were not from the version of the Plan in effect at the time of the

accident, but that is immaterial to this case.

ORDER, page 4

received the UB 92 and HCFA 1500 forms. She called Mr. Kilduff’s office and left

a voice mail message saying she needed the forms to process the claims.

22. Amco settled the claim for underinsured motorist insurance benefits by agreeing to

pay $200,000.00. Amco named the Estate on both in the Underinsured Motorist

Receipt and Release and on the $200,000.00 check.3

23. On February 6, 2004, Mr. Kilduff again wrote to HealthComp asking that they pay

the medical expenses.

24. There was no further contact between the Estate and HealthComp between

February 6, 2004 and May 24, 2004. 

25. This action was filed on May 24, 2004. 

26. On July 14, 2004, HealthComp’s Legal Compliance Manager, Scott Aitchison,

phoned Mr. Kilduff, and documented the call in a follow-up letter that same day. 

Mr. Aitchison informed Mr. Kilduff that HealthComp had no record of receiving

any claims for Ms. Trivitte in connection with her fatal accident, and thus

HealthComp had not processed any such claims nor made any adverse

determinations on the matter. Along with his letter, Mr. Aitchison sent Mr. Kilduff

a Group Medical Claim Form, and excerpts from the Plan regarding how to submit

a claim.4 Mr. Aitchison asked Mr. Kilduff to follow the procedure set forth in the

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ORDER, page 5

plan to submit the claim, but noted that HealthComp was not guaranteeing the claim

would be paid.

27. Mr. Kilduff filled in and returned the Group Medical Claim Form to HealthComp,

but expressly noted he was not conceding that no claim had previously been filed.

28. On August 4, 2004, HealthComp issued written denials of the Estate’s claims. The

stated reasons for denials were “Unable to verify underlying claim–hospital UB92

needed. Possible Third Party Liability–accident details needed. Timely filing

period has expired” and “Req’d info never rec’d–UB92 unable to obtain from

provider and patient. Possible TPL – need accident details. Timely filing period

has expired”

B. LEGAL ANALYSIS

1. De Novo Review Is Warranted in this Case

A district court reviews an ERISA plan benefits denial “under a de novo standard unless the

benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for

benefits or to construe the terms of the plan.” Firestone Tire and Rubber Co. v. Bruch, 489 U.S.

101, 115 (1989). Where a plan does give the administrator such discretionary authority, courts

review a claim denial under an abuse of discretion standard. See Snow v. Standard Ins. Co., 87 F.3d

327, 330 (9th Cir. 1996). In assessing whether a claim administrator abused its discretion, the court

considers whether the claim denial was unreasonable. Clark v. Washington Teamsters Welfare

Trust, 8 F.3d 1429, 1432 (9th Cir. 1993). 

However, even if a plan gives the administrator discretionary authority, as is the case here,

de novo review is warranted if the plan administrator fails to timely exercise that discretion and act

on the claim. See Jebian v. Hewlett-Packard Co., 349 F.3d 1098, 1106-07 (9th Cir. 2003) cert.

denied, 125 S.Ct. 2956 (2005) (“ ‘[T]o be entitled to deferential review, not only must the

administrator be given discretion by the plan, but the administrator’s decision in a given case must

be a valid exercise of that discretion.’ ”), quoting Gilbertson v. Allied Signal, Inc., 328 F.3d 625, 631

(10th Cir. 2003). 

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ORDER, page 6

In the present case, Defendants failed to exercise their discretion within the time allowed

under the Plan. The Plan provides that:

“A Plan Participant will be notified within 90 days of receipt of the claim as to the

acceptance or denial of a claim and if not notified within 90 days, the claim shall be

deemed denied.” (Plan at p. 68)

As mentioned above, Mr. Kilduff’s April 16, 2003 letter to HealthComp constituted a

timely claim for benefits. Defendants failed to make any decision on the claim for well over 90

days. Thus, the Estate’s claim was “deemed denied” as of July 15, 2003. Further, Defendants are

not entitled to invoke the safe harbor allowed for plan administrators who allow the time to lapse,

but are otherwise engaged in a “genuine, productive, ongoing dialogue” that substantially complies

with a plan’s timeline. See Jebian, 349 F.3d at 1105-08. 

Here, Defendants did almost nothing to administer the claim during the allowed time. 

They failed to send written notice to the Estate’s attorney stating what additional information they

needed. They failed to put their request to the medical providers for the UB92 and HCFA 1500

forms in writing. They failed to inform the Estate’s attorney how to submit a formal claim, and

did not even send him a claim form (which includes an authorization for providers to release

information regarding the patient). They did not ask the Estate’s attorney to provide any other

authorization for providers to release information. Finally, they did not contact the Estate’s

attorney again prior to the expiration of the 90 days to ensure he understood they were waiting for

him to obtain the forms for them. 

Even if Plaintiff’s counsel intentionally ignored the request for him to obtain the forms, that

would not excuse Defendants from fulfilling the rest of their obligations under ERISA. Had

Defendants followed up with a written request for the information, and then exercised their

discretion and issued a timely written denial based on Plaintiff’s failure to assist in obtaining the

information, Defendants would have been entitled to the abuse of discretion standard and a finding

that they did not abuse their discretion. (More likely, such written communications would have

inspired more cooperation from Plaintiff’s counsel and avoided this lawsuit.) But that is not what

happened here. As Scott Aitchison admitted in his July 14, 2004 letter to Mr. Kilduff, over a year

after the claim was submitted HealthComp had not processed the Estate’s claim, nor made any

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5

See footnote 1, supra.

6 The denials fail to meet all the requirements set forth on pages 67 & 68 of the Plan

document, as well as the requirements for the contents of a denial that were set forth in 29 C.F.R. section

2560.503-1(g) in that the denials do not refer to “the specific plan provisions on which the determination

is based,” and do not describe “any additional material or information necessary for the claimant to

perfect the claim and an explanation of why such material or information is necessary.”

7

It was in the Northern California Golf Association’s self-interest to deny the claim

because it funds the Plan and thus could save money by denying claims. It was in HealthComp’s selfinterest to deny the claim to save the cost of any further administration the claim, since HealthComp

receives only $10.00 per claim regardless of the amount of time and expense involved in administering

each claim. Moreover, it was in both Defendants’ self-interest to find an excuse to deny the claim in

order to cover up for their prior failure to properly administer the claim.

ORDER, page 7

adverse determinations on the matter. Because Defendants failed to exercise their discretion, they

are not entitled to the abuse of discretion standard of review.

The purported written denials issued in August of 2004 were untimely and did not cure

Defendants’ prior failure to administer the claim. In any event, de novo review of those denials

would be appropriate because the Plan Administrator’s apparent conflict of interest tainted the

decision. See Atwood v. Newmont Gold Co., Inc., 45 F.3d 1317, 1323 (9th Cir. 1995) (de novo

review appropriate if apparent conflict of interest inherent in a self-funded plan taints the decision of

the plan administrator). 

The August 2004 “denials” cite both a failure to receive requested information from either

Plaintiff or the providers, and the expiration of the timely filing period. These two rationales are

inconsistent under the facts of this case. The claims were only untimely if July 15, 2004–the date

Plaintiff’s counsel returned the official claim form–is used as the filing date.5 The failure to receive

requested information is only a valid reason for denial if Defendants made reasonable efforts to

obtain the information after the claims were filed. Given that the denials were dated August 4, 2004,

using a filing date of July 15, 2004 would mean that Defendants allowed less than three weeks for

receipt of the information they needed. Defendants’ belated, post-litigation request that Plaintiff

submit a claim form, the inconsistent reasons offered for the denials, and the fact the purported

denials did not meet the requirements of either the Plan or ERISA,6 all create a strong inference that

Defendants’ actions were designed to protect their own self-interest7 rather than to exercise their

discretion and administer the Plan in good faith.

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ORDER, page 8

2. Admission of Evidence Outside the Administrative Record Is Warranted.

When the standard of review in an ERISA benefits case is de novo, the court has discretion

to hear evidence outside the administrative record. Mongeluzo v. Baxter Travenol Long Term

Disability Benefit Plan, 46 F.3d 938, 943-44 (9th Cir. 1995). Courts admit evidence outside the

administrative record “only when circumstances clearly establish that additional evidence is

necessary to conduct an adequate de novo review of the benefit decision.” Ibid. (quoting

Quesinberry v. Life Ins. Co. of North America, 987 F.2d 1017, 1025 (4th Cir. 1993) (en banc)). In

the present case, admission of evidence outside of the administrative record is warranted, because

the record contains almost none of the information necessary to administer the claim. 

3. Determination of Benefits Due Under the Plan

In an action for benefits under ERISA, the Plaintiff carries the burden to establish the

amount of benefits due, if any. See, e.g., McMackins v. Monsanto Company Salaried Employees’

Pension Plan, 98 F.Supp.2d 1073, 1081 (E.D. Mo. 2000) (“plaintiff has the burden of presenting

evidence to show the amounts she is due”). Plaintiff failed to carry that burden in this case. 

The court expected, and would have admitted into evidence, the UB92 and HCFA 1500

forms related to Ms. Trivitte’s medical treatments, evidence of what the “allowable charges” were

as defined by the Plan, and further evidence regarding other available insurance and third party

liability. Unfortunately, Plaintiff did not offer into evidence the UB92 and HCFA 1500 forms, nor

any evidence of what the “allowable charges” were as defined by the Plan (nor even which, if any,

of the providers were “Network Providers”). And very little evidence regarding other available

insurance and third party liability was offered into evidence.

Although Plaintiff submitted some billing statements showing how much the providers

billed, Plaintiff failed to present any evidence that would allow the court to determine what portion

of the billed amounts are “covered charges” under the Plan. 

The Plan includes the following provisions:

“Medical benefits apply when covered charges are incurred by a Covered Person for

care of an Injury or Sickness and while the person is covered for these benefits

under the Plan.” (Plan at p. 25.)

“Each Calendar Year, benefits will be paid for the covered charges of a Covered Person

that are in excess of the deductible and any copayments. Payment will be made at the rate

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ORDER, page 9

shown under Percentage Payable in the Schedule of Benefits. No benefits will be paid in

excess of the Maximum Benefit Amount or any listed limit of the Plan.” (Plan at p. 25.)

“Covered charges are the Usual and Reasonable Charges that are incurred for the following

items of service and supply. These charges are subject to the benefit limits, exclusions and

other provisions of this Plan.” (Plan at p. 26.)

The “following items of service and supply” include hospital care, physician care and

necessary land or air ambulance. (See Plan at p. 27-28.)

The Plan defines “Usual and Reasonable Charges” as:

“a charge which is not higher than the usual charge made by the provider of the care or

supply and does not exceed the usual charge made by most providers of like service in the

same area. * * * *

“The Plan will reimburse the actual charge billed if it is lesser [sic] than the Usual and

Reasonable Charge.” (Plan at p. 52-53.)

The Plan’s Schedule of Benefits provides, in relevant part, that:

“All benefits described in this Schedule are subject to the exclusions and limitations

described more fully herein, including, but not limited to, the Plan Administrator’s

determination that: care and treatment is Medically Necessary; that charges are

Usual and Reasonable; that services, supplies and care are not Experimental and/or

Investigational. * * * *

“The Plan is a plan, which contains a Network Provider Organization.

“This Plan has entered into an agreement with certain Hospitals, Physicians and

other health care providers, which are called Network Providers. Because these

Network Providers have agreed to charge reduced fees to persons covered under the

Plan, the Plan can afford to reimburse a higher percentage of their fees.” (Plan at

p. 14)

In order to determine the amount of benefits due under the Plan, the court would need

information regarding whether or not each provider is a Network Provider. From Ms. Tovar’s

testimony that she would need to contact the “PPO Network” for pricing, the court infers that the

providers were most likely Network Providers. For Network Providers, the court would need

information regarding what the agreed upon reduced charges were for the services and supplies at

issue. If any of the providers were not Network Providers, the court would need, at a minimum,

information regarding the usual charges made by that provider, and the usual charges made by

most providers of like service or supplies in the same area, for the services and supplies at issue. 

See, e.g., Florence Nightengale Nursing Service, Inc. v. Blue Cross/Blue Shield of Alabama, 41 F.3d

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8

In his closing argument, Plaintiff’s counsel admitted he didn’t know whether the charges

were “usual and reasonable.” There is no excuse for that lack of knowledge and corresponding lack of

evidence. After this court denied Defendants’ motion for summary judgment, it expressly invited the

parties to move to open discovery if either party determined discovery was necessary. To the extent

Plaintiff’s counsel could not obtain evidence regarding the reasonableness of the charges without

discovery, he should have obtained permission from the court to conduct discovery on that issue.

Instead, he chose to do nothing. Plaintiff’s counsel fails to explain why he never sought to obtain copies

of the UB 92 and HCFA 1500 forms from the providers for use in proving Plaintiff’s damages at trial.

Nor does he explain why he never sought to conduct discovery regarding what amount of the medical

expenses incurred to transport Ms. Trivitte and treat her injuries were “covered” charges under the Plan.

While Defendants may have been responsible for determining that amount during administration of the

claims, once this matter reached trial that burden was on Plaintiff. Plaintiff cannot rely on Defendants’

earlier failure to make the determination to excuse Plaintiff’s own failure to do so at trial.

ORDER, page 10

1476, 1482-83 (11th Cir. 1995) (upholding trial court’s reliance on affidavit submitted by plaintiff

in finding rate for nursing care was reasonable). Plaintiff failed to present any such evidence at

trial.8 

Although Plaintiff presented billing statements from the providers, undisputed testimony

from HealthComp’s President, Philip John Musson, established that the amounts in such billing

statements are usually higher than the “Usual and Reasonable Charges” covered by the Plan, and

are routinely reduced based on the prior agreements with Network Providers (or negotiated down

with non-Network Providers). Thus, the billing statements alone are insufficient to establish what

the Usual and Reasonable Charges are for the services and supplies at issue.

Further, the Plan includes various provisions for the coordination of benefits with any other

relevant insurers, as well as a subrogation provision and an “other insurance” provision which

specifically declares that the Plan pays only “excess” benefits when medical payments are

available under any vehicle insurance. (See Plan at pp. 70-76.) Plaintiff submitted insufficient

evidence for the court to determine how the availability of funds from third-party tortfeasors, their

insurers, and Ms. Trivitte’s own underinsured motorist coverage effect the amount of benefits that

were due to Plaintiff under the Plan.

As to the subrogation issue, Plaintiff’s counsel made a point of testifying that he asserted

claims against the third-party tortfeasors, their insurer and the Estate’s underinsured motorist

coverage solely on behalf of Hobie Trivitte in his individual capacity, and that the settlement

proceeds were all paid to Hobie Trivitte, not the Estate. But the question is not whether the Estate

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9 The evidence at trial established that the Estate was named as payee on a $200,000.00

settlement with Ms. Trivitte’s insurer under her underinsured motorist coverage. Mr. Kilduff’s

subjective belief that the money belonged to Mr. Trivitte does not resolve serious issues this case raises

with regard to both men’s fiduciary obligations to seek recovery from that source on behalf of the Estate.

And on the record before the court, it is not at all clear that Mr. Trivitte was entitled to recover anything

from Ms. Trivitte’s underinsured motorist coverage for his wrongful death claim. There is no evidence

he was a named insured, or in any other way was covered under Ms. Trivitte’s policy.

10 From the fact that a settlement was also obtained from the Estate’s underinsured motorist

coverage, the court infers that the $50,000 Trivitte obtained in settlement with the third-party tortfeasors

exhausted the policy limits of their liability policy.

11 While Plaintiff’s counsel made a point of testifying he did not learn benefits might be

available under the Plan until April of 2003 (which was after Trivitte settled his own claim against the

third-parties and their insurer), as an experienced Plaintiff’s attorney it is inconceivable counsel did not

realize his actions were jeopardizing the ability of her health insurer, whoever that might be, to seek

subrogation. In any event, in order to adequately represent the Estate, counsel should have promptly

inquired to determine what health insurance Ms. Trivitte had at the time of her death. No showing was

made that any such inquiry was made before the Estate’s personal representative and counsel decided

to pursue the personal representative’s claims and to forego pursuing any claims by the Estate against

the third-parties (despite their respective fiduciary obligations to pursue such claims on behalf of the

Estate).

ORDER, page 11

actually received any money from these sources,

9

 but rather: 1) how much was available to the

Estate; 2) whether the Estate “execute[d] and deliver[ed] all required instruments and papers as

well as doing whatever else [was] needed to secure the Plan’s right of subrogation” which is a

condition of payment under the Plan (see Plan at p. 76); and 3) whether the Estate did “nothing to

prejudice the right of the Plan to subrogate” (see Plan at p. 76). It appears from the testimony at

trial that the Estate breached the subrogation provision of the Plan by failing to assert a claim

against the third-party tortfeasors before the Estate’s personal representative settled his own claims

against them in exchange for the policy limits10 of their liability insurance.11 Defendants are not

liable for the amount of money that would have been available for subrogation purposes, absent

Plaintiff’s breach of the subrogation clause. See Liberty Mut. Ins. Co. v. Altfillisch Constr. Co., 70

Cal.App.3d 789, 797 (1977) (where insurance policy contained subrogation provision, acts by

insured that cut off insurer’s opportunity for subrogation against the tortfeasor under policy’s

subrogation clause constituted a breach of the implied covenant of good faith and fair dealing by

the insured, and relieved insurer of any obligation to pay corresponding benefits under the policy). 

Defendants also presented evidence showing that up to $200,000.00 was available from

Ms. Trivitte’s underinsured motorist coverage, some or all of which should have been available for

Case 5:04-cv-03125-PVT Document 71 Filed 05/25/06 Page 11 of 12
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12 The court does not here imply that Defendants’ right to subrogation from the third-party

tortfeasors, their insurers and Ms. Trivitte’s underinsured motorist coverage had priority over

Mr. Trivitte’s wrongful death claims. However, neither did Mr. Trivitte’s claims have priority over the

Estate’s claims (and Defendants’ attendant subrogation rights). Properly handled, Mr. Trivitte as the

personal representative for the Estate, and Mr. Kilduff as counsel for the Estate, should have asserted

claims on behalf of the Estate at the same time they asserted Mr. Trivitte’s personal claims. The

settlements should have then been apportioned between the Estate and Mr. Trivitte, and approval of the

appropriate court sought in light of the conflict of interest between Trivitte and the Estate. To the extent

the amount the Estate recovered in settlement for medical expenses fell short of the amount of “covered

charges” under the Plan, the Plan would have been responsible to make up the difference. On the record

before the court, the settlement proceeds totaled $250,000, over three times the medical expenses at issue

in this lawsuit. Plaintiff has not established what the appropriate apportionment of the settlement

proceeds should have been, nor what amount, if any, Defendants would have been responsible to pay

absent Plaintiff’s breach of the subrogation provision.

ORDER, page 12

subrogation. Mr. Kilduff testified that the entire $200,000.00 was distributed to himself and

Mr. Trivitte. Plaintiff has not shown that any benefits remain due after subtracting whatever

amount properly should have been available for subrogation.12

C. CONCLUSIONS OF LAW

1. Defendants failed to administer the claim and it was deemed denied on July 15,

2003.

2. The proper standard of review in this case is de novo.

3. Admission of evidence outside of the administrative record is warranted.

4. Plaintiff failed to carry his burden to submit evidence sufficient to establish what, if

any, amount of benefits are due, and thus Defendants are entitled to judgment in

their favor.

II. JUDGMENT

Based on the foregoing findings of fact and conclusions of law.

IT IS HEREBY ADJUDGED, that Judgment be, and hereby is, entered in favor of

Defendants and against Plaintiff.

Dated: 5/25/06

 

PATRICIA V. TRUMBULL

United States Magistrate Judge

Case 5:04-cv-03125-PVT Document 71 Filed 05/25/06 Page 12 of 12