Opinion ID: 676599
Heading Depth: 2
Heading Rank: 2

Heading: Derivative Claim

Text: 21 Lordmann argues that the district court erred in granting summary judgment on its claim as Mitchell's assignee under the Hi-Fi group insurance plan. The plan contains two provisions that Lordmann claims entitle it to payment. The first provides 80% coverage for the first thirty days of home nursing coverage in each calendar year. Lordmann does not dispute that Equicor has paid the amount due under that provision. However, Lordmann insists that it is also entitled to recover as Mitchell's assignee under a term covering rehabilitation services. The plan provides: 22 This applies only to a person who: (a) is insured for Health Care Benefits; and (b) while so insured has suffered a severe personal injury or sickness. 3 If he or she becomes totally disabled due to such injury or sickness, the Employer [Hi-Fi] and the Company [Equicor] may agree that: 23 1. The Company pay benefits for reasonable and customary charges for rehabilitation services and supplies furnished to such person; and 24 2. Such benefits will be paid to the extent that they are in excess of the total benefits payable for such charges under all other parts of the plan.... The amount of such benefits will be determined by the Company. 25 (R1-17-Ex. 3, Plan Booklet at 16.) The provision unambiguously requires that Equicor and Hi-Fi agree for the additional benefits to become available. Lordmann argues that Castagno's representations to Marot were sufficient to put in issue the existence of an agreement. We disagree. The provision requires that both Hi-Fi and Equicor agree, and Lordmann has not presented evidence to suggest that Hi-Fi assented to Equicor's coverage of Victoria's care. 4 The district court was therefore correct in granting summary judgment for Equicor on Count III.