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Appellate Court Date: 2018.12.28
09:42:33 -06'00'
Marque Medicos Farnsworth, LLC v. Liberty Mutual Insurance Co.,
2018 IL App (1st) 163351
Appellate Court MARQUE MEDICOS FARNSWORTH, LLC, and MEDICOS PAIN
Caption & SURGICAL SPECIALISTS, S.C., Plaintiffs-Appellants, v.
LIBERTY MUTUAL INSURANCE COMPANY and ADVANCED
URETHANE TECHNOLOGIES, INC., d/b/a/ REM Innovations, Inc.,
and/or Sleep Innovations, Inc., Defendants-Appellees.
District & No. First District, Second Division
Docket No. 1-16-3351
Filed June 26, 2018
Decision Under Appeal from the Circuit Court of Cook County, No. 13-L-13457; the
Review Hon. James E. Snyder, Judge, presiding.
Judgment Affirmed.
Counsel on Alan J. Mandel and Antonio D. Flores, of Alan J. Mandel, Ltd., of
Appeal Skokie, for appellants.
John F. Boyle and Cathleen M. Hobson, of Law Offices of Meachum,
Boyle & Trafman, of Chicago, for appellees.
Panel PRESIDING JUSTICE MASON delivered the judgment of the court,
with opinion.
Justices Pucinski and Hyman concurred in the judgment and opinion.
OPINION
¶1 This case arises out of defendant-appellant Liberty Mutual Insurance Company’s
(Liberty) alleged failure to fully pay plaintiffs-appellees, Marque Medicos Farnsworth, LLC,
and Medicos Pain & Surgical Specialists, S.C. (collectively, the providers), for services they
rendered to an injured employee of codefendant-appellant, Advanced Urethane Technologies,
Inc., d/b/a REM Innovations, Inc., and/or Sleep Innovations, Inc. (Sleep Innovations).1 The
trial court dismissed with prejudice the providers’ claims for breach of contract, breach of
contract implied in law, breach of contract implied in fact, and recovery under section 155 of
the Illinois Insurance Code (215 ILCS 5/155 (West 2012)). Because we conclude that the
providers have no direct action against Liberty for its delay in paying medical bills, we affirm.
¶2 BACKGROUND
¶3 The providers filed suit against defendants in November 2013, alleging that they had not
been paid for treatment they provided to Martha Llamas, an injured employee of Sleep
Innovations. In their third amended complaint, at issue here, the providers alleged that Llamas
suffered a work-related injury on March 25, 2009, for which they provided treatment between
March 26, 2009, and January 26, 2011. At the outset of her treatment, Llamas authorized
payment to be made directly to the providers for insurance benefits payable to her. Initially, the
providers billed Sleep Innovations but were soon directed to submit their bills directly to
Liberty, which issued the workers’ compensation insurance policy to Sleep Innovations.
¶4 The insurance policy provides that Liberty would “pay promptly when due the benefits
required of [Sleep Innovations] by the workers compensation law,” and goes on to state that
Liberty is “directly and primarily liable to any person entitled to the benefits payable by this
insurance” and enforcement of this provision may be against Liberty or Sleep Innovations. The
policy also prohibits Sleep Innovations from making payments, assuming obligations, or
incurring expenses “except at [its] own cost.”
¶5 On May 1, 2009, Llamas filed a claim before the Illinois Workers’ Compensation
Commission (IWCC) for disability benefits and medical expenses, which was ultimately
settled in December 2012. The settlement agreement named Llamas as petitioner and Sleep
Innovations as respondent, but left blank the space to name respondent’s insurance or service
company. The terms of the settlement provided that respondent would pay “all necessary and
related medical expense pursuant to the fee schedule or negotiated rate, whichever is less, that
have been submitted to respondent prior to contract approval.” The settlement agreement was
silent on the amount of medical bills outstanding as of the date of its execution. The complaint
did not allege and the record does not disclose that, prior to the settlement, Liberty ever took
the position that all or any portion of the medical expenses reflected in the bills sent to it were
1
This case is related to Marque Medicos Archer, LLC v. Liberty Mutual Insurance Co., 2018 IL
App (1st) 163350, also decided today, in which Marque Medicos Archer and Medicos Pain & Surgical
Specialists, S.C., alleged that Liberty Mutual failed to fully pay for services the providers rendered to
an injured employee of a different corporation. Because the causes of action asserted by the providers
and dismissed by the trial court are not identical and because the parties did not move to consolidate the
cases, we decide them separately.
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not necessary or related to Llamas’s injuries or that the documentation in the bills was
insufficient.
¶6 Liberty eventually made late payments of medical bills in the amount of $80,000 to the
providers, but over $5200 in bills are still outstanding. In addition, Liberty failed to pay any
statutory interest on both the unpaid bills as well as the late paid bills, and the amount of
interest due as of the date of the complaint exceeded $24,000.
¶7 Based on these allegations, the providers alleged four counts against both defendants: (1)
breach of contract (based on the insurance policy), (2) violation of section 8.2(d) of the
Workers’ Compensation Act (Act) (820 ILCS 305/8.2(d) (West 2012)), (3) breach of contract
implied in law, and (4) breach of contract implied in fact; one count was alleged only against
Liberty, namely, recovery under section 155 of the Illinois Insurance Code (215 ILCS 5/155
(West 2012)).
¶8 Defendants filed a motion to dismiss the complaint pursuant to section 2-615 of the Code
of Civil Procedure (735 ILCS 5/2-615 (West 2012)). Ultimately, the trial court dismissed with
prejudice the providers’ claims for breach of contract, breach of contract implied in law,
breach of contract implied in fact, and violation of section 155 of the Illinois Insurance Code.
The providers timely appealed.
¶9 ANALYSIS
¶ 10 A motion to dismiss pursuant to section 2-615 of the Code of Civil Procedure challenges
the legal sufficiency of a complaint based on defects apparent on its face. Marshall v. Burger
King Corp., 222 Ill. 2d 422, 429 (2006). Examining the legal sufficiency of a complaint
requires us to accept as true both well-pleaded facts and reasonable inferences that we can
draw from those facts. Id. Further, we must construe the complaint’s allegations in the light
most favorable to the plaintiff. Napleton v. Village of Hinsdale, 229 Ill. 2d 296, 305 (2008). A
cause of action should not be dismissed unless there is no set of facts that can be proved that
would allow recovery. Pooh-Bah Enterprises, Inc. v. County of Cook, 232 Ill. 2d 463, 473
(2009). We review de novo an order dismissing a complaint under section 2-615. Id.
¶ 11 Turning first to the providers’ claim for breach of contract, this is premised on the
allegation that the providers are third-party beneficiaries of the workers’ compensation policy
issued by Liberty to Sleep Innovations. We answered this question in the negative in Marque
Medicos Fullerton, LLC v. Zurich American Insurance Co., 2017 IL App (1st) 160756, ¶¶ 1-4,
in which medical providers who provided care to injured employees brought putative class
actions against employers’ workers’ compensation insurers on the basis that their failure to
timely pay for services violated the Act. We decline to depart from Zurich today.
¶ 12 There is a strong presumption against conferring contractual benefits on noncontracting
third parties. Barry v. St. Mary’s Hospital Decatur, 2016 IL App (4th) 150961, ¶ 82. To
overcome this presumption, it is not sufficient if the parties know, expect, or even intend that
others will benefit from the agreement (see Estate of Willis v. Kiferbaum Construction Corp.,
357 Ill. App. 3d 1002, 1008 (2005)); instead, the language of the agreement must show that the
contract was made for the direct, not merely incidental, benefit of the third party (Carson Pirie
Scott & Co. v. Parrett, 346 Ill. 252, 257 (1931)). This intention may be shown by an express
provision in the contract identifying the third party by name or by a description of the class to
which the third-party beneficiary belongs. Martis v. Grinnell Mutual Reinsurance Co., 388 Ill.
App. 3d 1017, 1020 (2009). The court in Zurich considered these principles and concluded that
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medical providers are incidental rather than direct beneficiaries of workers’ compensation
policies. Zurich, 2017 IL App (1st) 160756, ¶ 53. We agree.
¶ 13 Significantly, the providers are not mentioned by name in the insurance contract attached
to the complaint, nor does the policy contain a description of a class to which the providers
belong. Just as in Zurich, we reject the providers’ claims that the policy language providing
that the insurer is “ ‘directly and primarily liable to any person entitled to benefits payable by
this insurance,’ ” is sufficiently specific to constitute a class description. (Emphasis added.) Id.
¶ 48.
¶ 14 The providers attempt to distinguish Martis, on which Zurich relied, arguing that the
Martis court did not consider how the policy language intersected with section 8.2(d) of the
Act, which provides for payments for medical treatments and services directly to providers
rather than the injured employee. See 820 ILCS 305/8.2(d) (West 2012). But the plaintiffs in
Zurich made a similar attempt to distinguish Martis, which the court rejected, explaining that
the fundamental purpose of the Act is to “ ‘afford protection to employees by providing them
with prompt and equitable compensation for their injuries.’ ” (Emphasis omitted.) Zurich,
2017 IL App (1st) 160756, ¶ 51 (quoting Kelsay v. Motorola, Inc., 74 Ill. 2d 172, 180-81
(1978)). The direct payment obligation of section 8.2(d) merely serves to further this purpose
and ensure that injured employees receive prompt payment of benefits owed to them. Id. ¶ 52.
Thus, the court held that even assuming the direct payment language entitled providers to
benefits under the Act, these benefits were incidental and did not render them third-party
beneficiaries of the insurance contract. Id. ¶ 53.
¶ 15 The existence of the settlement agreement between Llamas and Sleep Innovations does not
alter our conclusion. The settlement agreement did not exist at the time Liberty issued Sleep
Innovations the workers’ compensation policy, and it is only the circumstances in existence at
the time of execution of the contract that determines whether they intended to benefit a third
party to the agreement. See Carson Pirie Scott, 346 Ill. at 258. In other words, to the extent that
the settlement agreement confers a benefit on the providers, it does not follow that the workers’
compensation policy was likewise intended to confer a benefit. The parties to the policy are
different than those to the settlement agreement, and both documents were executed at
different times for different purposes.
¶ 16 The providers next challenge the dismissal of their claim for breach of contract implied in
law. A contract implied in law, also referred to as a quasi-contract, is not a contract at all, and
exists independent of any agreement or consent of the parties. Village of Bloomingdale v. CDG
Enterprises, Inc., 196 Ill. 2d 484, 500 (2001). Instead, it is premised on an implied promise by
the recipient of goods or services to pay for something of value that it has received. Karen
Stavins Enterprises, Inc. v. Community College District No. 508, County of Cook, 2015 IL App
(1st) 150356, ¶ 7. The cause of action is based on the principle that no one may unjustly enrich
himself at another’s expense. Trapani Construction Co. v. The Elliot Group, Inc., 2016 IL App
(1st) 143734, ¶ 41.
¶ 17 In order to state a cause of action for a breach of contract implied in law, a plaintiff must
allege “specific facts in support of the conclusion that it conferred a benefit upon the defendant
which the defendant has unjustly retained in violation of fundamental principles of equity and
good conscience.” Karen Stavins Enterprises, 2015 IL App (1st) 150356, ¶ 7. It is sufficient to
note that the complaint alleges no facts specifying the benefit the providers bestowed on
defendants; they provided a benefit—namely, medical services—only to the injured employee.
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As such, the providers have failed to state a cause of action for breach of contract implied in
law.
¶ 18 Nor have the providers stated a claim for breach of contract implied in fact. A contract
implied in fact is imposed by the court where there is some expression or promise that can be
inferred from the facts and circumstances. Citizen’s Bank-Illinois, N.A. v. American National
Bank & Trust Co. of Chicago, 326 Ill. App. 3d 822, 831 (2001). It contains all the elements of
an express contract, namely, “an offer, a strictly conforming acceptance to the offer, and
supporting consideration.” Brody v. Finch University of Health Sciences/The Chicago Medical
School, 298 Ill. App. 3d 146, 154 (1998).
¶ 19 At issue here is whether the providers adequately alleged the element of consideration.
Zabaneh Franchises, LLC v. Walker, 2012 IL App (4th) 110215, ¶ 17 (“ ‘Valid consideration,
on the part of both parties, is one of the essential requirements for the formation of a contract
***.’ ” (quoting Agrimerica, Inc. v. Mathes, 199 Ill. App. 3d 435, 441 (1990))). Consideration
is a detriment to the offeror or benefit to the offeree, or “some bargained-for exchange between
them.” Doyle v. Holy Cross Hospital, 186 Ill. 2d 104, 112 (1999). Significantly, there is no
consideration when a party promises to do what it is legally obligated to do. Diederich
Insurance Agency, LLC v. Smith, 2011 IL App (5th) 100048, ¶ 12 (citing White v. Village of
Homewood, 256 Ill. App. 3d 354, 357 (1993)).
¶ 20 Here, just as in Zurich, the providers allege that an implied in fact contract was formed in
which defendants agreed to pay Llamas’s medical bills and any statutory interest directly to the
providers in exchange for the providers’ agreement to follow the defendants’ “instructions
regarding billing.” But in the providers’ complaint, they allege that defendants were obligated
under the insurance contract and the Act to pay Llamas’s medical bills and statutory interest.
Because acts performed pursuant to preexisting legal duties cannot constitute valid
consideration and because valid consideration on the part of both parties is necessary for the
formation of a contract, the providers have not stated a claim for breach of contract implied in
fact. See Zurich, 2017 IL App (1st) 160576, ¶¶ 66-67.
¶ 21 Finally, the providers allege a cause of action pursuant to section 155 of the Illinois
Insurance Code (215 ILCS 5/155 (West 2012)). Section 155 provides:
“In any action by or against a company wherein there is in issue the liability of a
company on a policy or policies of insurance or the amount of the loss payable
thereunder, or for an unreasonable delay in settling a claim, and it appears to the court
that such action or delay is vexatious and unreasonable, the court may allow as part of
the taxable costs in the action reasonable attorney fees, other costs, plus [certain
penalties.]” Id.
¶ 22 Our supreme court has held that the section 155 remedies extend only to the insured party
and assignees of the insurance policy, and not to third parties. Zurich, 2017 IL 160756, ¶ 71
(citing Yassin v. Certified Grocers of Illinois, Inc., 133 Ill. 2d 458, 466 (1990)). This
long-standing rule prompted the court in Zurich to conclude that medical providers, as
third-parties to the contracts between the insurer and insured employers, are not entitled to
recover under section 155 of the Illinois Insurance Code. Id. We agree.
¶ 23 The Zurich court distinguished Garcia v. Lovellette, 265 Ill. App. 3d 724 (1994), on which
the providers here also rely. Zurich, 2017 IL App (1st) 160756, ¶ 72. In Garcia, the plaintiff, a
passenger in the defendant insured’s car at the time of an accident, argued that she was entitled
to recovery under section 155 for the insurer’s allegedly unreasonable and vexatious delay in
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paying her medical bills. Garcia, 265 Ill. App. 3d at 725-26. The insurer contended that the
plaintiff was a third-party claimant and, as such, lacked standing to bring a cause of action
pursuant to section 155. Id. at 726. This court disagreed, based on the fact that the insurance
policy defined an occupant of the named insured’s car as an insured, thereby entitling the
plaintiff to bring a section 155 claim. Id. at 728. Here, in contrast, the policy does not name the
providers as insureds, and we have already concluded that they are not third-party beneficiaries
of the policy. It is irrelevant that Llamas assigned her rights to collect insurance benefits to the
providers, as Llamas, too, is not an insured under the workers’ compensation policy.
¶ 24 The conclusion we reach today should not be construed to mean that we condone Liberty’s
conduct in failing to pay outstanding medical bills and interest as it is obligated to do under
both the Act and its insurance policy. Accepting the well-pled allegations of the providers’
complaint as true, Liberty’s conduct in (i) accepting premiums under a policy of insurance that
renders it “directly and primarily liable” for benefits payable under the Act, (ii) authorizing a
settlement agreement that plainly contemplates payment of those benefits, and (iii) claiming
after the fact that no benefits are payable threatens the stability and predictability of benefits
the Act is designed to provide. See McMahan v. Industrial Comm’n, 183 Ill. 2d 499, 514
(1998) (“The refusal of an employer to pay for an injured employee’s medical expenses is as
contrary to the purposes of the [Act] as an employer’s refusal to compensate the employee for
lost earnings. *** Indeed, to the extent that nonpayment of medical expenses may imperil the
employee’s ability to obtain future treatment, the consequences of the employer’s actions may
actually be far worse.”). Many employees, like Llamas, accept a lump sum settlement to cover
not only past medical care but also medical care reasonably anticipated to be necessary in the
future. But if a workers’ compensation carrier can authorize a settlement whereby the
employer undertakes to pay past due bills and then fail to remit policy proceeds to cover that
obligation, the pool of medical providers willing to render services to patients suffering
work-related injuries will necessarily diminish.
¶ 25 During oral argument, counsel for Liberty took the position that Sleep Innovation’s
commitment in the settlement agreement “to pay all necessary and related medical expenses”
was essentially illusory. This is because Liberty, to whom all of the medical bills had been
submitted and who was obligated to “promptly” pay those bills, had not agreed that the
medical expenses incurred by Llamas were “necessary and related.” In other words, Liberty’s
position is that it may remain silent when medical bills are submitted directly to it, authorize its
policyholder to enter into a settlement whereby the policyholder undertakes to pay those
outstanding bills, and then leave both its policyholder and the injured worker on the hook for
unpaid bills after the fact.
¶ 26 We do not read the Act as giving Liberty the option to refrain from raising any issues
regarding the reasonableness of bills submitted to it until after its policyholder has, with its
approval, committed to pay them. Rather, the Act contemplates that when an insurer receives
bills allegedly relating to a work-related injury, the insurer will promptly raise any issues
regarding whether the services rendered were reasonable and related to the employee’s injury
or whether the detail in the bills is insufficient to make that determination. 820 ILCS
305/8.2(d) (West 2012). As far as the record here discloses, Liberty never raised any such
issues after receipt of bills from Marque Medicos Farnsworth, LLC.
¶ 27 Accepting the complaint’s allegations as true, as we must, such conduct appears to be a
textbook example of “vexatious and unreasonable” claims handling practices under section
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155 of the Illinois Insurance Code (215 ILCS 5/155 (West 2012)). In a companion case
decided today, Marque Medicos Archer, LLC v. Liberty Mutual Insurance Co., 2018 IL App
(1st) 163350, ¶¶ 5-6, we discussed that, as alleged in the complaint in that case, the Director of
Insurance conducted a market conduct examination of Liberty’s claims handling practices
specifically related to the payment of interest on adequately documented provider bills and
that, as a result, Liberty entered into a stipulation and consent order whereby Liberty
committed to institute and maintain procedures for the payment of interest. We take judicial
notice here of the results of the market conduct examination. In re Nylani M., 2016 IL App
(1st) 152262, ¶ 36 (“A court may take judicial notice of matters generally known to the court
and not subject to reasonable dispute.”). The Director of Insurance should pay close attention
to whether Liberty is, in fact, living up to its obligations under the stipulation and consent
order. To that end, we are directing the clerk of the court to send a copy of the opinion to the
Director of Insurance.
¶ 28 But as egregious as Liberty’s conduct appears to be, it does not translate into recognition of
a direct action by providers against Liberty. Rather, when the legislature enacted section 8.2 of
the Act by amendment in 2011, it simultaneously created a remedy for its violation. In
particular, section 8.2(e-20) provides that after a final award by the IWCC, a provider may
resume efforts to collect unpaid bills from the employee and “the employee shall be
responsible for payment of any outstanding bills *** as well as the interest awarded under
subsection (d) of this Section.” 820 ILCS 305/8.2(e-20) (West 2012). At first blush, the ability
to pursue the injured employee for payment of outstanding medical bills appears to run counter
to the overarching purpose of the Act to protect the interests of injured workers. But the
legislature may well have assumed that an employee who receives an award from the IWCC is
the party responsible for paying outstanding medical bills from the award. When, as here, that
is not the case, the methods of enforcing a workers’ compensation carrier’s obligation to pay
outstanding medical bills are varied and somewhat circuitous.
¶ 29 Under the Act, the IWCC lacks authority to enforce its own awards and decisions.
Millennium Knickerbocker Hotel v. Illinois Workers’ Compensation Comm’n, 2017 IL App
(1st) 161027WC, ¶ 21 (citing Smith v. Gen Co., 11 Ill. App. 3d 106, 110 (1973)). Therefore, in
order to enforce an employer’s obligation to pay an award, the employee must look elsewhere.
¶ 30 One possible scenario is that when the providers pursue payment of outstanding bills from
the employee, the employee, in an effort to enforce the IWCC award, can present a certified
copy of the award to the circuit court under section 19(g) of the Act (820 ILCS 305/19(g)
(West 2012)), in order to reduce the award to judgment. The employer, upon whom the
obligation to pay is imposed under the award (and the judgment entered on the award), can, in
turn, pursue a third-party action against its insurer for breach of the workers’ compensation
insurance policy and, presumably, for a violation of section 155 of the Illinois Insurance Code
(215 ILCS 5/155 (West 2012)). If the circuit court finds that there has been a failure to pay the
employee in accordance with the IWCC award, section 19(g) further mandates an award of
attorney fees and costs incurred by the employee not only in the circuit court action but also in
the proceedings before the IWCC.
“In a case where the employer refuses to pay compensation according to such final
award or such final decision upon which such judgment is entered the court shall in
entering judgment thereon, tax as costs *** the reasonable costs and attorney fees in the
arbitration proceedings and in the court entering the judgment for the person in whose
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favor the judgment is entered ***.” (Emphasis added.) 820 ILCS 305/19(g) (West
2012).
And the fees and costs recovered by the employee as well as the employers’ own attorney fees
and costs would be compensable damages proximately caused by the insurer’s breach of
contract. In the end, the recalcitrant insurer would end up paying its own, its insured’s and the
employee’s attorney fees and costs, plus whatever sums the court deemed appropriate under
section 155. See 215 ILCS 5/155(1) (West 2012) (providing for an award of up to $60,000 in
addition to attorney fees and costs). Accordingly, the price of an insurer’s decision to stonewall
payment of benefits due under an IWCC award is, indeed, steep.
¶ 31 Alternatively, there are two provisions of the Act that provide for the award by the IWCC
of additional compensation to the employee in the case of nonpayment of benefits. First,
section 19(k) of the Act authorizes the employee to seek and the IWCC to award additional
compensation equal to 50% of the amount otherwise payable to the employee if the employer
vexatiously delays in paying benefits due under the Act. 820 ILCS 305/19(k) (West 2012). In
the event the IWCC determines that a penalty is appropriate under section 19(k), section 16 of
the Act further authorizes an award of attorney fees and costs “against such employer and his
or her insurance carrier.” Id. § 16. Second, section 19(l) contemplates that an employee may
file a written demand for payment of benefits for necessary medical care payable under section
8(a). Id. § 19(l). In the event of such written demand, the employer must respond within 30
days, articulating in writing the reason for the delay. Section 19(l) further provides:
“In case the employer or his or her insurance carrier shall without good and just cause
fail, neglect, refuse, or unreasonably delay the payment of benefits under Section 8(a)
***, the Arbitrator or the Commission shall allow to the employee additional
compensation in the sum of $30 per day for each day that the benefits under Section
8(a) *** have been so withheld or refused, not to exceed $10,000.” (Emphasis added.)
Id.
¶ 32 What is common to all of these alternative courses of action is that they must be undertaken
by the employee for whose benefit these provisions were enacted. Which brings us to another,
less circuitous means of avoiding this problem in the future. Attorneys handling workers’
compensation cases on behalf of claimants must be cognizant of their clients’ potential
post-award exposure to claims by medical providers for unpaid bills. As noted, if, as happened
here (and apparently in a number of other cases involving Liberty), the employer does not
fulfill its undertaking to pay outstanding medical bills, providers are permitted to pursue
payment from the injured employee. With that in mind, competent counsel should insist that
any settlement agreement contain a sum certain that the employer has agreed to pay for
outstanding medical bills and also contain a representation that the employer has consulted
with its insurance carrier and secured the carrier’s commitment to pay that amount upon
execution of the settlement. The settlement here contained no such detail and merely provided
that Sleep Innovations “will pay all necessary and related medical expenses *** that have been
submitted prior to contract approval and that contain all the required data elements.” This lack
of specificity permitted Liberty to “lay in the weeds” to the employee’s, the providers’ and,
ultimately, its own policyholder’s detriment.
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¶ 33 CONCLUSION
¶ 34 We affirm the trial court’s dismissal of the providers’ claims for breach of contract, breach
of contract implied in law, breach of contract implied in fact, and recovery pursuant to section
155 of the Illinois Insurance Code. We further order the clerk of the court to send a copy of
this opinion to the Director of Insurance.
¶ 35 Affirmed.
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