United States District Court, D. Massachusetts
ROBERT SUMMERSGILL, NAMED PERSONAL REPRESENTATIVE OF THE ESTATE OF JEAN SUMMERSGILL, Plaintiff,
E.I. DUPONT DE NEMOURS & CO., BENEFLEX MEDICAL CARE PLAN AND MEDICAL CARE ASSISTANCE PROGRAM, AND AETNA LIFE INSURANCE CO., Defendants.
MEMORANDUM AND ORDER
DENISE J. CASPER, UNITED STATES DISTRICT JUDGE.
Plaintiff Robert Summersgill, representative of the estate of Jean Summersgill, (“Summersgill”) brings this action against Defendants E.I. du Pont de Nemours and Company (“DuPont”), Beneflex Medical Care Plan and Medical Care Assistance Program, and Aetna Life Insurance Co. (“Aetna”) (collectively, “Defendants”) under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001, et seq. (“ERISA”) alleging that Defendants improperly denied his late mother, Jean Summersgill (“Mrs. Summersgill”) reimbursement for certain care she received at a Christian Science facility. Defendants and Summersgill have moved for summary judgment. D. 88; D. 92; D. 94. For the reasons set forth below, Defendants’ motions for summary judgment are ALLOWED and Summersgill’s motion for summary judgment is DENIED.
A. The Plan
The following facts are drawn from the administrative record submitted to the Court by DuPont, D. 105, Summersgill’s statement of material facts, D. 89, Defendants’ response, D. 102, and Defendants’ statement of material facts,  D. 96.
Mrs. Summersgill, as the surviving spouse of Elmer Hibbard Summersgill, received health benefits under DuPont’s Medical Care Assistance Program (“Plan”), described in the Summary Plan Description (“SPD”). D. 96 ¶ 1; D. 102 ¶ 2. DuPont serves as the Plan Administrator and Aetna, through an Administrative Services Agreement with DuPont (“Administrative Agreement”), D. 98, and as outlined in the SPD, AR 687, 695-96, is Claims Administrator and medical carrier, AR 696. As such, Aetna initially reviews and manages the claims for benefits which DuPont ultimately pays. D. 98 at 2-3, 8; AR 685. Under the Plan, DuPont has full discretion and authority to interpret Plan provisions, resolve any ambiguities and evaluate claims. AR 635. DuPont decides the “final appeal” for any claim denied under the Plan. AR 635, 687; D. 95 at 3. In making such a determination “with regard to whether a particular treatment, drug or other item is . . . not medically necessary or appropriate, [DuPont] shall consult with a health care professional who has appropriate training and expertise in the field of medicine involved in the medical judgment.” AR 688.
To challenge a determination of benefits, a beneficiary of the Plan, after receiving written notice from Aetna of the denial or partial denial of a claim, first contacts and appeals to Aetna (what the parties refer to as a “Level 1 appeal”). AR 686-87. If the claim is not adequately resolved with Aetna and Aetna denies an appeal, a beneficiary may then make a final appeal to DuPont (a “Level 2 appeal”). AR 687. An appeal to DuPont must be made in a timely manner, preferably 60 days after a claim is denied. Id. Depending on the circumstances, DuPont will provide information regarding a final decision within 60 days. Id. The Plan requires exhaustion of the “claim and appeal procedure . . . before seeking any other legal recourse regarding claims for benefits.” Id.
The Plan, subject to certain exclusions, pays covered expenses for a “Christian Science Facility - unlimited days for room and board and nursing care in lieu of inpatient hospital care.” AR 626; see AR 671. “Inpatient” is defined in the SPD as “[w]hen you are admitted to the hospital for treatment or observation.” AR 699. The term “hospital” is defined as:
An institution which is primarily engaged in providing for compensation and on an inpatient basis, for the surgical and medical care, diagnosis and treatment of persons through medical, diagnostic and major surgical facilities. These facilities must be provided on the institution’s premises, under the supervision of a staff of physicians and with twenty-four-hour-a-day registered graduate nursing services; or
An institution which is accredited as a hospital by the Joint Commission on Accreditation of Hospitals, or which the Contract Administrator designates.
The term “hospital” shall not include any institution (or any part of an institution), which is used other than incidentally as a convalescent facility, nursing home, rest home, or a facility for the aged.
The Plan specifically excludes certain services and supplies from covered expenses:
• Charges for services or supplies not medically necessary for the diagnosis and treatment of the illness or injury, except for preventative procedures described herein;
• Charges for services or supplies specifically to maintain a level of well-being, and;
• Charges for custodial care, regardless of who recommends or provides the care.
AR 627, 683-84. Notably, the SPD states-in describing covered services, including those provided at a Christian Science facility-that “[a]ll care must be medically necessary.” AR 670- 71. “Medically necessary” is defined as:
a service or supply, which is reasonable and necessary for the diagnosis or treatment of an illness or injury, in view of the customary practice in the geographical area, and is given at the appropriate level of care.
AR 617, 699. “Custodial care” is defined as:
treatment of persons who have reached the maximum level of recovery which can reasonably be expected, or care primarily for purposes of meeting a person’s needs which could be provided by persons without professional skill or training.
AR 617, 698.
B. Mrs. Summersgill’s Care and Claims
From June 2008 through December 27, 2012, Mrs. Summersgill, an elderly woman and life-long Christian Scientist, D. 102 ¶ 1, received Christian Science care at Chestnut Hill Benevolent Association (“CHBA”), id. ¶ 5. According to CHBA’s records in 2010, Mrs. Summersgill received most care in bed and was “[c]hallenged with weakness, sudden needs when [she] has become unresponsive and stopped breathing;” “[d]ifficulty with nourishment due to difficulty chewing and swallowing, ” requiring assistance for feeding; “pain in back, head, neck and legs when moving and turning” and “[d]ifficulty with moving head, ” requiring assistance; limited mobility and range of motion in ...