Wesson v. Jane Phillips Medical Center & Affiliates Employee Group Healthcare Plan, Premium Plan
Wesson v. Jane Phillips Medical Center & Affiliates Employee Group Healthcare Plan, Premium Plan
Opinion of the Court
OPINION & ORDER
Before the Court in ERISA
BACKGROUND
A. Policy Coverage and Provisions
Throughout 2005 and 2008, the relevant years in this case, Plaintiff was an employee of Defendant Jane Phillips Medical Center (“JPMC”) and was a participant in JPMC’s group health plan (“Plan”).
Morbid Obesity — The Plan covers obesity treatment if such treatment is deemed Medically Necessary and diagnosed as a condition in which an individual is obese as defined by the National Heart, Lung, and Blood Institute, and its guidelines of 1998 if the following criteria is met: (1) A body mass index of 40 or over 35 if the patient has other existing co-morbid diagnosis (as determined by the Body Mass Index table). (2) The patient is evaluated by a surgeon, psychiatrist and nutritionist. (3) The patient selects a surgeon with experience in gastric bypass surgery procedures. (4) A plan of treatment is submitted by the surgeon to case management for review. Treatment of complications (to include other organs), as a result of obesity services(s) will not be covered by this Plan. See your Plan Supervisor for a copy of the institute’s guidelines as well as the Medical Exclusions and Limitations in this booklet for more information.
Payment under this benefit will be limited to: Lifetime Maximum of $15,000.
In 2008 Plaintiff experienced health problems, such as depression, lack of appetite, acid reflux, inability to keep solid foods down, and weight loss.
B. Administrative Adjudication of Plaintiff’s Claim.
Plaintiff sought coverage for these 2008 doctor visits and medical procedures by submitting health insurance claims to the Plan.
On October 8, 2008 BMI issued its decision, confirming the denial of Plaintiffs claim, citing that Plaintiffs claim exceeded the Plan’s $15,000 lifetime limit for medical services connected with morbid obesity based on its determination that the 2008 procedures resulted from a complication of the original 2005 gastric bypass.
On January 9, 2009, Plaintiff initiated an appeal to Plan administrator JPMC.
Defendant JPMC gathered all of Plaintiffs appeal materials and the medical records related to the 2008 surgeries and submitted them to HealthReview, L.L.C., an independent medical review company.
Defendant JPMC then submitted the materials to AUMed Healthcare Management (AllMed) for further independent medical review.
C. Relevant Procedural Background
In her Complaint, Plaintiff states claims for (1) enforcement of ERISA benefits under the plan, and (2) breach of fiduciary duty.
DISCUSSION
A. Standard of Review
Here, it is uncontested that the language of the plan clearly gives JPMC ultimate authority to determine eligibility benefits and construe the terms of the plan.
The Court accepts Plaintiffs contention that JPMC’s position as both the final arbiter of Plaintiffs claims and the payor of those claims creates an inherent conflict of interest.
B. Defendants’ Review of Plaintiffs Claims
In analyzing Defendants’ review of Plaintiffs claims, the Court first reviews Plaintiffs allegations regarding BMI’s failure to comply with the requirements of ERISA in its explanation of benefits (EOB) and claim denial letters.
1. Initial BMI Review
Plaintiff alleges that the EOB forms notifying Plaintiff of the initial denial of benefits are inadequate under ERISA procedure.
ERISA procedure requires that an administrator’s reason for denial “must be stated in reasonably clear language.”
The Court first questions whether or not BMI’s initial determination clearly stated the specific reason or reasons for the claim denial as required by ERISA. The initial EOB form letters received by Plaintiff state only that the type of service rendered was “Weight Control PI” and that Plaintiffs claims exceed the maximum plan allowance.
Defendant argues that these are sufficient to clearly convey the specific reason for denial of Plaintiffs claims so that Plaintiff could understand and challenge the denial.
Plaintiffs argument is undercut by the information presented in her initial appeal letter to BMI.
2. Plaintiffs Request for Review to BMI
Plaintiff also alleges that the notification provided by BMI’s October 8, 2008 denial letter regarding her request for review was “woefully inadequate,” as BMI did not provide an evidentiary basis for its conclusion that Plaintiffs 2008 procedures were the result of complications from her 2005 operation.
(i) The specific reason or reasons for the adverse determination;
(ii) Reference to the specific plan provisions on which the determination is based;
(in) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary;
(iv) A description of the plan’s review procedures and the time limits applicable to such procedures, including a statement of the claimant’s right to bring a civil action under section 502(a) of the Act following an adverse benefit determination on review.51
Further, if the adverse benefit determination is based on an exclusion or limit, the administrator must provide either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant’s medical circumstances, or a statement that such explanation will be provided free of charge upon request.
The October 8, 2008 letter states that (a) the reviewer relied on the claims previously processed in order to come to its decision, that (b) the reviewer’s clinical judgment was that the procedures were the result of complications arising from a previous bariatric surgery, and that (c) plan language, provided in the letter, specifically barred claims related to complications arising from the surgery. Although not particularly informative, it comports with the notice requirements of 29 C.F.R. § 2560.503-l(g) in that it (a) states the specific reason for the adverse determination, including the evidence used to come to that determination (b) references the specific plan language on which the determination was based, and (c) explained the clinical judgment of the reviewer by applying specific terms of the plan to Plaintiffs 2008 medical procedures based on the information contained in the claims for benefits.
Plaintiff also contends that BMI failed to inform her of what documentation or other evidence she might consider submitting.
Addressing Plaintiffs protestations that BMI’s notice failed to provide a “meaningful dialogue” between a claimant and the claims administrator as required by the statute,
In simple English, what this regulation calls for is a meaningful dialogue between ERISA plan administrators and their beneficiaries. If benefits are denied ... the reason for the denial must be stated in reasonably clear language, ... if the plan administrators believe that more information is needed to make a reasoned decision, they must ask for it. There is nothing extraordinary about this: it’s how civilized people communicate with each other regarding important matters.58
The BMI denial letter sets out that Plaintiffs claim was denied because the 2008 procedures and surgeries were found to be the result of complications from the 2005 obesity surgery. Further, Plaintiff was informed that she could submit supplemental material if she wished. However, the plan administrators apparently did not believe they needed more information to make a reasoned decision on appeal and therefore did not ask for it. Nothing more is needed to establish the “meaningful dialogue” contemplated by the statute.
Finally, Plaintiff also alleges that BMI’s October 8, 2008 denial letter failed to inform Plaintiff she was entitled to be represented in pursuing her claims and failed to describe additional material that was needed to perfect her claim.
(3) To the extent that a plan offers voluntary levels of appeal (except to the extent that the plan is required to do so by State law), including voluntary arbitration or any other form of dispute resolution, in addition to those permitted by paragraph (c)(2) of this section, the claims procedures provide that:
(iii) The claims procedures provide that a claimant may elect to submit a benefit dispute to such voluntary level of appeal only after exhaustion of the appeals permitted by paragraph (c)(2) of this section;
(iv) The plan provides to any claimant, upon request, sufficient information relating to the voluntary level of appeal to enable the claimant to make an informed judgment about whether to submit a benefit dispute to the voluntary level of appeal, including a statement that the*1272 decision of a claimant as to whether or not to submit a benefit dispute to the voluntary level of appeal will have no effect on the claimant’s rights to any other benefits under the plan and information about the applicable rules, the claimant’s right to representation, the process for selecting the decisionmaker, and the circumstances, if any, that may affect the impartiality of the decision-maker, such as any financial or personal interests in the result or any past or present relationship with any party to the review process;
Section (c)(2) of 29 C.F.R. § 2560.503-1, referenced above, states that a claims procedure will be deemed reasonable if:
“[t]he claims procedures do not contain any provision, and are not administered in a way, that requires a claimant to file more than two appeals of an adverse benefit determination prior to bringing a civil action under section 502(a) of the Act.”
Reading these two statutory sentences in conjunction, one can clearly see that section (c)(3) addresses the reasonableness and delineates the standards for a voluntary appeals process outside the maximum two mandatory appeals allowed under 29 C.F.R. § 2560.503-l(c)(2). As such, the “upon request” standards regarding notification of a claimant’s right to representation outlined in section (c)(3) are inapplicable to the instant case, as Plaintiff is seeking relief in this Court based on her mandatory appeals, rather than an additional voluntary appeal or arbitration process. Plaintiff offers no other statutory language that purports to require notice of a right to representation.
Ultimately, the October 8, 2008 denial letter notified Plaintiff as to the basis of BMI’s findings and provided Plaintiff with adequate notice from which she could perfect an appeal to the plan administrator. Consequently, the Court finds that BMI substantially complied with ERISA notification requirements with regard to the October 8, 2008 review and denial letter.
3. JPMC Appeal
It is uncontested that the language of the plan gives JPMC the ultimate authority to determine eligibility benefits and construe the terms of the plan.
Plaintiffs alleges that JPMC failed to rely on substantial evidence in
Here the Administrative Record shows that JPMC first contacted HealthReview, L.L.C. to perform an independent review of Plaintiff’s claim, specifically stating “I am particularly interested to know if he/she can comment on whether a person who had not had the bypass procedure would have experienced the same stricture issue under the stressful circumstances.”
JPMC does admit that the nurse’s findings were secondary considerations to Dr. Freedman’s report, and it was Dr. Freedman’s report on which it primarily based its decision to refuse benefits.
The fact that Dr. Freedman apparently remained unaware of the actual procedure performed in 2005, despite being informed of the basic nature of the procedure in the question presented by JPMC, causes the Court to question Dr. Freedman’s diligence in preparing the report. Further, Dr. Freedman’s faulty presumption that Plaintiff underwent a vertical banded gastroplasty, followed by reference to a gastric bypass in his conclusion demonstrates either loose language in reference to varying bariatric procedures or ignorance of the procedures in general. Such imprecision in a field that demands precision is unacceptable. As such, the Court cannot find that this report, standing by itself, is “evidence that a reasonable mind might accept as adequate to support the conclusion reached by the decisionmaker.”
However, Dr. Freedman’s report was not the only evidence available to JPMC in making the determination on Plaintiffs claims. The Administrative Record before JPMC also included the informal response by the HealthReview, L.L.C. nurse and, more importantly, the operative notes and medical records related to Plaintiffs 2008 procedures and surgery. Review of the 2008 medical records reveals that Plaintiff was having some dysfunction with the Silastic ring, a medical device implanted during her 2005 procedure, which required the first two dilation procedures.
Ultimately, because Plaintiff would have neither the Silastic ring, nor the gastrojejunostomy absent the 2005 surgery, it is reasonable to conclude that none of the 2008 procedures would be necessary but for the 2005 procedure. Because the 2008 procedures and surgery were specifically to correct problems related to the 2005 operation, the 2008 procedures and surgery can reasonably be considered treatment for complications stemming from the
Finally, Plaintiffs allegations that JPMC did not consider that Plaintiffs condition may have been brought on by stress and that JPMC ignored the medical “evidence” she provided during the BMI review are without merit.
The articles point out that GERD can result in esophageal strictures, among other esophageal problems.
The law is clear: the Court cannot substitute its own judgment for that of the plan administrator unless the administrator’s actions are without any reasonable basis.
C. Breach of Fiduciary Duty
Plaintiffs Complaint includes an allegation that “[i]n the denial of benefits for the 2008 surgery and related expenses, [ ]JPMC [ ] breached their fiduciary duties to [Plaintiff].”
Although ERISA § 404(a)(1) states that Plan assets “shall be held for the exclusive purposes of providing benefits to participants in the plan and their beneficiaries,” nothing in the statute states that such funds must be segregated into separate interest-bearing trust accounts. The Tenth Circuit has also not addressed whether or not ERISA employee contributions to healthcare plans must be segregated into interest bearing trust accounts, and Plaintiff has offered no other case law to support her allegation. In fact, JPMC’s decision not to segregate plan funds into a separate trust account appears to comport with standard industry practice with regard to welfare plans, including healthcare plans like the one at issue here.
The Second Circuit, in Nechis v. Oxford Health Plans, Incorporated has addressed this issue to some degree. In Nechis, the Circuit Court upheld a district court finding that a plan administrator had no obligation to segregate the plan premiums from the general operating account.
As in Nechis, the instant Plaintiff apparently seeks to impose a constructive trust on employee contributions to the Plan that would obligate it to segregate employee contributions to the Plan into a separate, interest-bearing trust account.
Ultimately, in order for an ERISA plaintiff to prevail on a breach of fiduciary duty claim under ERISA § 409, “there must be a showing of some causal link between the alleged breach and the loss plaintiff seeks to recover.”
Because, JPMC is not obligated to segregate Plan premiums as Plaintiff contends, Plaintiff cannot demonstrate a breach of any duty. Further, Plaintiff has offered no competent evidence that this alleged breach resulted in losses to the Plan, denial of Plaintiff’s benefits, or ill-gotten gains to JPMC. As Plaintiff has failed to offer evidence supporting either prong of the standard set forth by the Circuit, Plaintiffs claim for breach of fiduciary duty based on JPMC’s failure to segregate employee contributions from its general operating funds must be DENIED.
CONCLUSION
For the reasons cited herein, Defendant JPMC’s final determination denying medical benefits payable to Plaintiff Wesson is hereby AFFIRMED. Plaintiffs claim for breach of fiduciary duty is DENIED. A separate Judgment is filed herewith.
. The parties have stipulated that this case is governed by ERISA. Joint Status Report at 3,
. Docket No.'s 42, 50, and 56.
. Docket No.'s 43, 48, and 57.
. See generally Administrative Record, Docket Nos. 32, 37, 64. The Administrative Record has been submitted to the Court at Docket No.’s 32, 37, and 64 and is labeled "Wesson Administrative Record’’ (Admin. Rec.) 1-180.
. Plaintiffs Opening brief at 2, Docket No. 42.
. See Admin. Rec. at 18-19.
. Id. 15-16, 105.
. Id. at 105.
. Id. at 18-19.
. See id. at 55-57, 69-70.
. Mat65.
. See id. 3-13.
. See id. at 18-20, 163-80.
. See id. at 18-20, Defendants’ Opening Brief at 3, Docket No. 43.
. See id.
. See id. at 50.
. Id.
.Id.
. Id. at 52-53.
. See id. at 57.
. See id. at 23-48.
. Id. at 83.
. Id. at 83, 87.
. Mat 79-80.
. Mat 79-80.
. Id. at 79.
. Id. at 89.
. See id. at 89; see generally Complaint, Docket No. 2.
. See id. at 6-7.
. See Docket No. 32.
. See Opinion and Order at 7, Docket No. 68.
. See id. at 3-4, n. 4, Docket No. 68 (citing Geddes v. United Staffing Alliance Emp. Med. Plan, 469 F.3d 919, 926 (10th Cir. 2006)).
. Plaintiffs Opening Brief at 11, Docket No. 42.
. Nance v. Sun Life Assurance Co. of Canada, 294 F.3d 1263, 1267-68 (10th Cir. 2002) (citing Chambers v. Family Health Plan Corp., 100 F.3d 818, 825 (10th Cir. 1996)).
. See Plaintiff's Opening Brief at 11-12, Docket No. 42.
. Holcomb v. Unum Life Ins. Co. of America, 578 F.3d 1187, 1192-93 (10th Cir. 2009).
. Id.
. See Plaintiff's Supplemental Response to BMI-Healthplans Amended Administrative Record (Plaintiff's Supplemental Response) at 4, Docket No. 65.
. Id. at 2-3.
. Metzger v. UNUM Life Ins. Co. of America, 476 F.3d 1161, 1168, n. 4 (10th Cir. 2007)(citing 29 C.F.R. § 2560.503-l(g)).
. Gilbertson, 328 F.3d at 635 (citing Booton v. Lockheed Medical Benefit Plan, 110 F.3d 1461, 1463 (9th Cir. 1997)).
. Id. at 634-35.
. Id. at 163-80.
. See id. at 171-74.
. See Reply by Defendants to Plaintiffs Supplemental Response at 2, Docket No. 66.
. See Plaintiff’s Supplemental Response at 7-8, Docket No. 65. See also Admin. Rec. at 163-170; 175-80; but see id. at 171-74.
. See Admin. Rec. at 19-20.
. Id. at 19.
. Plaintiff's Opening Brief at 14-15, Docket No. 42, Plaintiff's Supplemental Response to BMI-Healthplan's Amended Administrative Record at 10, Docket No. 65.
. 29 U.S.C. § 1133.
. 29 C.F.R. § 2560.503 — l(g)(l)(i)—(iv).
. 29 C.F.R. § 2560.503-1 (g)(v)(B).
. See Hatpin v. W.W. Grainger, Inc., 962 F.2d 685, 693 (7th Cir. 1992).
. Plaintiff's Supplemental Response to BMIHealthplan's Amended Administrative Record at 10, Docket No. 65.
. 29 C.F.R. § 2560.503 — 1 (g)(l)(iii).
. See Plaintiffs Response Brief at 12, Docket No. 50 ("[N]or does BMI anywhere in that letter identify or suggest to [Plaintiff] what documents or evidence she might submit on appeal that might be helpful to support her claim for benefits”).
. Gilbertson v. Allied Signal, Inc., 328 F.3d 625, 635 (10th Cir. 2003).
. Id. (citing Booton v. Lockheed Medical Benefit Plan, 110 F.3d 1461, 1463 (9th Cir. 1997)).
. Plaintiffs Response Brief at 12, Docket No. 50
. Plaintiff's Opening Brief at 11, Docket No. 42.
. Nance v. Sun Life Assurance Co. of Canada, 294 F.3d 1263, 1267-68 (10th Cir. 2002) (citing Chambers v. Family Health Plan Corp., 100 F.3d 818, 825 (10th Cir. 1996)).
. Geddes v. United Staffing Alliance Employee Medical Plan, 469 F.3d 919, 929 (10th Cir. 2006) {internal citations omitted).
. Id.
. See Holcomb v. Unum Life Ins. Co. of America, 578 F.3d 1187, 1192-93 (10th Cir. 2009) (embracing a combination-of-factors method of review).
. See Plaintiff's Opening Brief at 19-21, Docket No. 42; Plaintiff’s Supplemental Response to BMI-Healthplan’s Amended Administrative Record at 10, Docket No. 65.
. Caldwell v. Life Ins. Co. of North America, 287 F.3d 1276, 1282 (10th Cir. 2002).
. Id. (internal quotations omitted).
. Id.
. Id. (internal quotations omitted).
. Admin. Rec. 83-87. Plaintiff alleges these are merely hearsay statements, and were not available to Plaintiff until after filing of this suit. Plaintiff's Response Brief at 8, Docket No. 50. The record indicates that the Plan Administrator relied on this evidence to some degree, before requesting further physician review, therefore it is relevant to the Court’s inquiry. As the emails were used in the determination of the final appeal, JPMC was not required to produce them to Plaintiff until after the review was complete. See Metzger, 476 F.3d 1161.
. Admin. Rec. at 83.
. Id. at 85.
. Reply Brief by Defendants Jane Phillips Medical Center & Affiliates Employee Group Healthcare Plan and Jane Phillips Medical Center at 6-7, Docket No. 57.
. Admin. Rec. at 79-80.
. Id.
. Id.
. Plaintiff's Opening Brief at 20-21, Docket No. 42.
. See Admin. Rec. at 80 ("Van Gemert WG, Van Wersh MM, Greve JW, Soeters PB. Revisional Surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastic bypass. Obesity Surg 1998 Feb; 8(l):21-8”) (emphasis in citation added).
. Id. at 79-80 (emphasis added).
. Id. (emphasis added).
. Id. (internal quotations omitted).
. Id. at 74-75.
. Id. at 65.
. See Response Brief of Defendants Jane Phillips Medical Center and Jane Phillips & Affiliates Employee Group Healthcare Plan at 10-11, Docket No. 48.
. See id.
. Plaintiff's Opening Brief at 16, 20, Docket No. 42.
. See Response Brief of Defendants Jane Phillips Medical Center and Jane Phillips & Affiliates Employee Group Healthcare Plan at 11, Docket No. 48.
. See Admin Rec. at 23-48, 58 (articles include Esophogeal Stricture; The Effect of Life Stress on Symptoms of Heartburn; Stress and Heartburn: a Biobehavioral Perspective; Diagnosis of Gastroesophageal Reflux Disease and Heartburn; Stress, Sickness, and Divorce; The Serious Consequences of GERD ).
. Id.
. Id. at 61-62 (medical records include drawings with notations “eso. — normal;” “stomach normal”).
. Geddes, 469 F.3d at 929 (internal citations omitted).
. Even if the Court were to accept Plaintiff's contention that JPMC's review was based solely on Dr. Freedman’s report, after its thorough review of the record, the Court is convinced that JPMC would arrive at its previous conclusion denying benefits even after thorough consideration of all relevant evidence. Consequently, remand to JPMC for further review is unnecessary and inappropriate. See Rekstad v. U.S. Bancorp, 451 F.3d 1114, 1121 (10th Cir. 2006) (citing Quinn v. Blue Cross & Blue Shield Ass’n, 161 F.3d 472, 478 (7th Cir. 1998)).
. Complaint at 7, Docket No. 1
. Plaintiff's Opening Brief at 23, Docket No. 42.
. See Plaintiff's Response Brief at 13-14, Docket No. 50; but see Affidavit of Michael Moore at 1-2, Docket No. 48-1.
. See, e.g., Eric D. Chason, Redressing All Fiduciary Breaches Under Section 409(a), 83 TEMPLE L.REV. 147, 150-51 (2010) (“While welfare plans may be ‘fiduciary relationships,’ the relationship is often not one ‘with respect to property' because benefits are paid directly from the employer's general assets rather than a segregated trust fund”)
. See Nechis, 421 F.3d 96, 103-04 (2nd Cir. 2005) (internal citations and quotations omitted ).
. Id.
. Id.
. Id.
. See Plaintiff's Opening Brief at 23, Docket No. 42 (“E. The Plan Administrator Breaches its Fiduciary Duty to Plan Beneficiaries by Failing to Maintain Employee Contribution in a Separate Interest-Bearing Trust Account, or Other Prudent Investment, and Instead Co-mingles Employee Contributions With General Operating Funds”).
. See Nechis, 421 F.3d at 103-04
. Holdeman v. Devine, 572 F.3d 1190, 1193 (10th Cir. 2009) (internal quotations and citations omitted).
. Holdeman v. Devine, No. 2:02-CV-00365 PGC, 2007 WL 3254969, *11 (D.Utah 2007).
Reference
- Full Case Name
- Susan WESSON v. 1. JANE PHILLIPS MEDICAL CENTER & AFFILIATES EMPLOYEE GROUP HEALTHCARE PLAN, PREMIUM PLAN and 2. Jane Phillips Medical Center
- Cited By
- 2 cases
- Status
- Published