Stacy S. v. Boeing Co. Emp. Health Benefit Plan
Stacy S. v. Boeing Co. Emp. Health Benefit Plan
Opinion of the Court
This case involves medical treatment that M.K., a minor, received from March 27 to July 1, 2013. Plaintiff, M.K.'s mother, brought this action for recovery of medical benefits that Defendants Boeing Company Employee Health Benefit Plan and ValueOptions (collectively, ValueOptions) denied. Plaintiff and ValueOptions each filed a Motion for Summary Judgment. For the reasons stated below, Plaintiff's Motion for Summary Judgment is DENIED
BACKGROUND
M.K. is a beneficiary of the Boeing Company Employee Health Benefit Plan (the Plan). Drawing on the criteria explained in the Plan, ValueOptions denied Plaintiff's request for coverage for M.K.'s stay at Aspen, a residential treatment center (RTC) in Utah.
The Plan Language
The Plan provides benefits for Boeing employees, spouses, and dependents. The summary plan description (SPD) states that the Boeing Company Board of Directors designated a committee to serve as Plan Administrator, which has the "absolute discretion" to "[d]elegate its administrative duties and responsibilities to persons or entities of its choice such as the Boeing Service Center, the service representatives, and employees of the Company."
The SPD also states a beneficiary may file a civil action in the district court within 180 days after "[d]ecision on appeal of your claim for benefits or eligibility."
Denial of Coverage
This case stems from a denial of coverage for M.K.'s stay at Aspen, an RTC. Prior to her stay at Aspen, M.K. had been hospitalized at Seattle Children's Hospital after Plaintiff discovered M.K. was cutting herself. M.K.'s physician at Seattle Children's Hospital modified M.K.'s medication, and M.K. was discharged on March 9, 2013, with her physician's recommendation that she participate in outpatient therapy.
M.K. was admitted to Aspen on March 27, 2013. An Aspen representative contacted ValueOptions to request authorization for M.K.'s inpatient mental health services. ValueOptions' medical director reviewed Aspen's request and concluded M.K. did not meet the criteria for acute in-patient hospitalization because she had shown improvement concerning her psychotic symptoms.
ValueOptions notified Plaintiff of her right to appeal this decision in a letter sent March 29, 2013.
Aspen notified ValueOptions that if M.K. stepped down to a lower level of care such as RTC services, Aspen would contact ValueOptions for precertification.
On May 13, ValueOptions received a claim from Aspen for RTC services provided from March 27 to April 30, 2013. ValueOptions denied the claim on the basis that the services had not been authorized.
ValueOptions' letter to Plaintiff notifying her of this decision recited the same clinical rationale as the March 27 letter, except it replaced "Acute Inpatient Hospitalization with 24 hour Medical Supervision" with "Residential Treatment Setting."
Plaintiff requested an appeal of the denial in April 2014. Plaintiff included a letter from M.K.'s outpatient therapist, who stated that long-term residential treatment "seems to be consistent with [his] impressions gathered over time, of [M.K.]'s growing needs."
ValueOptions notified Plaintiff of this decision on May 1, 2014.
Plaintiff requested an external appeal, which Allmed was randomly selected to conduct. Allmed reviewed Plaintiff's appeal letters, M.K.'s medical records from Aspen, ValueOptions' denial letter, the Plan language, and ValueOptions' clinical criteria for child/adolescent RTC services. Allmed notified Plaintiff on October 16, 2014 that the RTC services were "not clinically appropriate, known to be effective for or consistent with the patient's condition, or in accordance with the generally accepted standards for residential care based on current literature."
Following the denials, Plaintiff filed her Complaint on June 5, 2015, seeking $79,350 for denied medical benefits.
LEGAL STANDARD
Where, as here, the parties in an ERISA case both move for summary judgment, *1330"the factual determination of eligibility for benefits is decided solely on the administrative record, and the non-moving party is not entitled to the usual inferences in its favor."
ANALYSIS
ValueOptions argues Plaintiff's civil action was untimely filed and should be dismissed. In the alternative, ValueOptions contends its decision to deny M.K. benefits was reasonable. Plaintiff argues the untimeliness of her action should be excused. She maintains the court should review the denial of benefits de novo, and hold that ValueOptions should have covered the RTC services.
I. Timeliness
ValueOptions first argues Plaintiff's claim must be dismissed as untimely because she did not file suit within 180 days of ValueOptions' final denial, as required by the Plan.
ERISA does not contain a limitations provision for district court actions, but parties may contractually agree on a time limit.
A. ERISA's requirements
Two sections of ERISA address the information a plan administrator is required to include in its adverse benefit determinations. The court includes below the entirety of both, observing that the first includes in Subsection (iv) reference to "the time limits applicable" to review procedures. This provision is noticeably absent in Subsection 4 of the second applicable ERISA section. The first relevant section,
(i) The specific reason or reasons for the adverse determination;
(ii) Reference to the specific plan provisions on which the determination is based;
(iii) 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 *1331Act following an adverse benefit determination on review.
The second relevant portion of ERISA, Section 2560.503-1(j), addresses "Manner and content of notification of benefit determination on review." This section requires an adverse benefit determination on review to include:
1) The specific reason or reasons for the adverse determination;
2) Reference to the specific plan provisions on which the benefit determination is based;
3) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits....
4) A statement describing any voluntary appeal procedures offered by the plan and the claimant's right to obtain the information about such procedures ... and a statement of the claimant's right to bring an action under section 502(a) of the Act.
The court must take into account both sections when determining whether an adverse benefit determination on review must include the applicable time limits for the claimant's right to bring an action under Section 502(a), which is the claimant's avenue to file a civil action in district court.
B. Split in authority
The majority of courts that have interpreted Section (g)(1)(iv) conclude it requires a plan administrator to include, in adverse benefit determinations, the time limits for a civil action.
The Tenth Circuit has not directly addressed this question. The Court addressed a related issue in Hancock v. Metropolitan Life Insurance , in which a claimant argued the plan administrator violated Sections (g)(1)(ii) and (g)(1)(iii) by providing her with a denial of an appeal that did not cite the provision upon which the denial was based and did not explain how she could perfect her claim.
*1332
Given the nature of a final denial, there was no reason for the Tenth Circuit to apply either Section (g)(1)(ii) or Section (g)(1)(iii) in the context of denial of an appeal. To begin with, Section (g)(1)(ii)'s requirement of a "[r]eference to the specific plan provisions on which the determination is based" is repeated nearly verbatim in Section (j)(2), making application of Section (g)(1)(ii) unnecessary for final denials. Additionally, Section (g)(1)(iii)'s requirement of a "description of any additional material or information necessary for the claimant to perfect the claim" is nonsensical in the context of a final benefit determination, because the claimant has already exhausted her opportunities to provide such additional information. Thus, Hancock 's determination that Sections (g)(1)(ii) and (g)(1)(iii) do not apply to final benefit determinations has no bearing on Section (g)(1)(iv)'s potential relevance.
The Tenth Circuit also addressed a similar issue in an unpublished decision, Young v. United Parcel Services .
Like Hancock, Young did not address the application of Section (g)(1)(iv). Additionally, two decisions in District of Utah cases have recently noted that Section (g)'s language is broader than the SPD in Young .
Because neither Hancock nor Young addressed Section (g)(1)(iv), district courts in the Tenth Circuit have been left with little guidance, giving rise to a split within this district.
The first District of Utah case to address this question was Michael C.D. v. United Healthcare .
The same issue was presented a year later in John H. v. United Healthcare .
This question arose again in William G. v. United Healthcare .
This court is now presented with the same issue. For largely the same reasons *1334articulated in the decision, the court agrees with the holdings in John H . and William G. , and concludes final benefit determinations must notify the claimant of the time limit to file an action in district court. This is explained more fully in the next Section.
C. Application of canons of statutory construction
When analyzing a regulation, the court applies ordinary principles of statutory construction.
The court recognizes that no reconciliation of Sections (g) and (j) would perfectly effect all the above-mentioned canons of statutory construction. Applying the plain language of Section (g) leads to the conclusion that "any adverse benefit determination" includes final determinations. But that reading renders several portions superfluous. If Sections (g)(1)(i) and (ii) already require a final determination to contain "[t]he specific reason or reasons for the adverse determination" and a "[r]eference to the specific plan provisions on which the determination is based," then there would be no need for Section (j) to repeat those requirements. Additionally, Section (g)(1)(iv)'s requirement that the plan administrator notify a claimant of the right to bring a civil action is repeated in Section (j)(iv) but without Section (g)'s language about time limits, which seems to implicate the negative-inference canon. Thus, no reading of the statute perfectly harmonizes the two sections.
Given this tension, the best solution is to rely on the plain language and conclude that any superfluousness that occurs is the result of Congress' intent to craft a statute that leaves no doubt as to the importance of explaining adverse benefit determinations to claimants.
Under this reading, Section (g)'s language concerning "any adverse benefit determination" includes final denials. The court finds no support in the plain language for the conclusion that Section (g) applies only to initial benefit determinations. Rather, the word "any" encompasses "final."
Additionally, the court agrees with the conclusion in William G . that giving meaning to the word "including" in Section (g)(1)(iv) must mean that a civil action is one of the "review procedures" for which a time limit must be provided. "[T]he word 'including' cannot be easily removed or changed since it modifies the word 'description,' which is followed by a prepositional phrase explaining what must be described-the plan's review procedures and applicable time limits for those procedures."
This interpretation admittedly results in some duplication of requirements between Sections (g) and (j), namely the reasons for the adverse determination, the reference to the provision on which the determination is based, and the notification of the right to file a civil action. But this duplication reflects ERISA's policy considerations. ERISA "is remedial legislation that should be construed liberally in favor of those persons it was meant to benefit, namely participants ... and beneficiaries."
to protect interstate commerce and the interests of participants in employee benefit plans and their beneficiaries, by requiring the disclosure and reporting to participants and beneficiaries of financial and other information with respect thereto, by establishing standards of conduct, responsibility, and obligation for fiduciaries of employee benefit plans, and by providing for appropriate remedies, sanctions, and ready access to the Federal courts.61
The duplication of Section (g)'s provisions serves to highlight several of those stated purposes, including the importance of disclosure of information to participants and ready access to federal courts.
Additionally, as the First Circuit Court of Appeals noted, "[c]laimants are obviously more likely to read information stated in the final denial letter, as opposed to included (or possibly buried) somewhere in the plan documents, particularly since, as was the case here, plan documents could have been given to a claimant years before his claim for benefits is denied."
Given the plain language of Sections (g) and (j), the court concludes a final benefit determination must notify the claimant of the time limit for filing a civil action.
D. Remedy for noncompliance
ValueOptions does not dispute that it failed to provide notification of the Plan's 180-day time limit. As the court recognized in William G. , "there are two potential consequences" for a plan's failure to notify claimants of the time limit for a civil action in final adverse benefit determinations-equitable tolling or "presuming prejudice and rendering the Plan's limitations period unenforceable."
ValueOptions does not argue the court should apply equitable tolling here, and, in any case, the court concludes equitable tolling would be inappropriate. Section (g) requires notification of the time limit in benefit determinations and does not appear to contemplate an alternative method of notification. To allow plan administrators to avoid this requirement through equitable tolling "would render hollow the important disclosure function of § 2560.503-1(g)(1)(iv), as plan administrators would then have no reason at all to comply with their obligation to include contractual time limits for judicial review in benefit denial letters."
*1336The better rule is that a plan administrator who fails to notify claimants of the time limit cannot rely on that time limit to bar a late-filed civil action.
Where no contractual time limit applies to an ERISA case, the court applies "the most closely analogous statute of limitations under state law."
II. Denial of benefits
Plaintiff urges the court to hold that ValueOptions should have covered M.K.'s RTC services at Aspen, while ValueOptions argues the court should uphold the denial. To resolve this question, the court must first determine which standard of review applies.
A. Standard of review
The court reviews a denial of benefits 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."
The Tenth Circuit has been "comparatively liberal in construing language to trigger the more deferential standard of review under ERISA."
For example, the Tenth Circuit has concluded that discretionary authority was granted where the plan grants authority "to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan,"
*1337Plaintiff argues a de novo review applies for two reasons: (1) the record contains only the SPD, not the Plan, and (2) even if the SPD is sufficient, it does not grant discretionary authority for determining benefits.
Plaintiff first argues that because the administrative record contains only the SPD and not the Plan itself, the court cannot determine whether the Plan grants discretionary authority to ValueOptions.
The Tenth Circuit rejected a similar argument in Eugene S. v. Horizon Blue Cross Blue Shield .
Plaintiff in this case has not requested that a copy of the Plan be placed in the administrative record or that the court delay its ruling. Additionally, the SPD states that it is part of the Plan and one of several "governing documents." Finally, Plaintiff has not argued what parts of the Plan are relevant to her arguments but not included in the SPD. Thus, the court concludes the language in the SPD is sufficient when analyzing whether the Plan grants discretionary authority.
Plaintiff also argues the Plan delegates discretionary authority to ValueOptions only for administrative duties and not for determining whether services should be covered. Plaintiff is correct that the Plan uses explicit delegation language only for "administrative duties and responsibilities."
There is no meaningful difference between the authority to "determine" benefits and the authority to "make benefit determinations." Both terms inherently require some exercise of discretion. The authority to make benefit determinations requires an analysis of the factors for coverage under the Plan, in contrast to cases in which a claim is "deemed denied" by operation of law.
B. Application of arbitrary and capricious standard
Under an arbitrary and capricious standard, the court's review "is limited to determining whether the interpretation of the plan was reasonable and made in good faith."
*1338Plaintiff argues ValueOptions's decision to deny the request for services was arbitrary and capricious because (1) the claims were not reviewed by physicians with the appropriate medical expertise, and (2) it did not provide a full and fair review by taking into account information submitted by Plaintiff.
1. Medical specialty of reviewing physicians
Plaintiff argues the ValueOptions and Allmed reviewers did not have a medical specialty or expertise comparable to M.K.'s treating physicians, and therefore their opinions did not provide a reasonable basis for the denials.
Under
Even assuming the identification and expertise of the reviewers did not satisfy Section (h)(3)(iii)'s requirements, the court concludes ValueOptions has substantially complied with ERISA and thus does not forfeit the deferential standard of review. ValueOptions has provided evidence that all three reviewers were psychiatrists, and Plaintiff has pointed to no authority that would require a more specific area of expertise in order to review an adolescent's claim. Thus, ValueOptions has substantially complied with Section (h)(3)(iii), and the arbitrary and capricious standard of review applies.
2. Full and fair review
Plaintiff argues ValueOptions did not take into account evidence she provided about M.K.'s condition and therefore did not provide a full and fair review.
ERISA plans are required to "afford a reasonable opportunity ... for a full and fair review by the appropriate named fiduciary of the decision denying the claim."
The Plan in this case provides six criteria for admission to RTC services, including whether the patient is "not sufficiently stable," can "respond favorably" to counseling and training, has "a history of poor treatment adherence or outcome," or has options for lower levels of care that are "appropriate to meet the individual's needs."
The record shows ValueOptions took these reports into account but did not conclude they required RTC services. The initial reviewing physicians focused on M.K.'s behavior after her discharge from the hospital, which would have provided the basis for RTC admission. One physician noted that between her discharge and her admission to Aspen, M.K. had only one instance of self-injurious behavior.
The criteria for admission to RTC services and continued stay are highly subjective. ValueOptions' determination that M.K. did not meet these criteria relied on the physicians' well-detailed reports about M.K.'s history of treatment and other available options. The contrary report from M.K.'s outpatient therapist-who provided therapy to M.K. only until 2012-evinces a difference of opinion concerning the criteria, but does not show the medical opinions ValueOptions relied upon were unreasonable. Thus, the court concludes ValueOptions provided a full and fair review of Plaintiff's claim.
While Plaintiff certainly had grounds for believing M.K. satisfied the criteria, the court cannot say that ValueOptions' denials were not based on any reasonable basis.
*1340CONCLUSION
The court concludes that Plaintiff's action was timely filed. However, ValueOptions' denial of benefits was reasonable. Thus, Plaintiff's Motion for Summary Judgment is DENIED,
SO ORDERED this 25th day of September, 2018. The Clerk of Court is directed to close the case.
Dkt. 30.
Dkt. 29.
R. 44.
R. 1215.
R. 1217.
R. 1147.
R. 1192.
R. 882.
R. 883.
R. 975.
R. 1021.
R. 973.
R. 979.
R. 981.
R. 91.
R. 880.
R. 986.
R. 1030.
R. 1036.
R. 1037.
Dkt. 2.
LaAsmar v. Phelps Dodge Corp. Life, Accidental Death & Dismemberment & Dependent Life Ins. Plan ,
Sandoval v. Aetna Life & Cas. Ins. Co. ,
Salisbury v. Hartford Life & Acc. Co. ,
Plaintiff also argues ValueOptions cannot enforce the contractual statute of limitations because (1) it failed to raise the time limit as an affirmative defense in its Answer, and (2) the sole reference to the 180-day deadline in the SPD was unclear, in violation of ERISA's requirement that the SPD "reasonably apprise such participants and beneficiaries of their rights and obligations under the plan."
See, e.g., Santana-Diaz v. Metro. Life Ins. Co. ,
See Santana-Diaz ,
See
See Santana-Diaz ,
William G. v. United Healthcare , No. 1:16-CV-00144-DN,
No. 2:15-CV-306-DAK,
Id. at *4-5,
Id. at *5,
No. 1:16-cv-110-TC,
Id. at *6.
Id. at *7 (internal quotation marks omitted).
Id. *13.
Id. *14.
No. 1:16-CV-00144-DN,
Id. at *5.
Id. at *6.
Time Warner Entm't Co., L.P. v. Everest Midwest Licensee, L.L.C. ,
Park 'N Fly, Inc. v. Dollar Park & Fly, Inc. ,
TRW Inc. v. Andrews ,
Hamdan v. Rumsfeld ,
William G. ,
Jenkins v. Green Bay Packaging, Inc. ,
Santana-Diaz ,
William G. ,
Santana-Diaz ,
Accord
Salisbury ,
Michael C.D. ,
R. 1030.
Dkt. 2.
Hancock v. Metro. Life Ins. Co. ,
Kellogg v. Metro. Life Ins. Co.,
Nance v. Sun Life Assur. Co. of Canada ,
Eugene S.,
Hancock ,
Geddes v. United Staffing Alliance Emp. Med. Plan ,
Henderson v. Hartford Life & Acc. Ins. Co. , No. 2:11-CV-187-DAK,
R. 1207.
R. 1215.
See Gilbertson v. Allied Signal, Inc. ,
LaAsmar ,
Kimber v. Thiokol Corp. ,
Dkt. 30 at 35.
Sandoval ,
Sage v. Automation, Inc. Pension Plan & Tr.,
Adamson v. Unum Life Ins. Co. of Am. , No. 2:98-CV-0286-TS,
Niedens v. Cont'l Cas. Co. ,
Flinders v. Workforce Stabilization Plan of Phillips Petroleum Co. ,
R. 87.
R. 88-89.
R. 989.
R. 1037.
The fact that ValueOptions used nearly the same language in its two denials does not alter this conclusion. The physicians' decisions were detailed in their treatment reports, and the letter informed Plaintiff she could request copies of those reports.
Dkt. 30.
Dkt. 29.
Reference
- Full Case Name
- STACY S., Individually and as Guardian of M.K., a Minor v. The BOEING COMPANY EMPLOYEE HEALTH BENEFIT PLAN (PLAN 626), and ValueOptions
- Cited By
- 6 cases
- Status
- Published