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Stephanie C. v. Blue Cross Blue Shield of Massachusetts HMO Blue, Inc.

United States District Court, D. Massachusetts

June 30, 2016

STEPHANIE C., individually and as guardian of MILES G., Plaintiff,
v.
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS HMO BLUE, INC., Defendant.

          MEMORANDUM AND ORDER

          Denise J. Casper United States District Judge

         I. Introduction

         Plaintiff Stephanie C. (“Stephanie”), individually and as guardian of Miles G. (“Miles”), has brought this action against Defendant Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. (“BCBS”) under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B), challenging BCBS’s partial denial of health insurance benefits for mental health treatment. D. 1. This Court previously denied Stephanie’s motion for summary judgment and allowed BCBS’s motion. Stephanie C. v. Blue Cross Blue Shield of Massachusetts HMO Blue, Inc., No. 13-cv-13250-DJC, 2015 WL 1443012, at *1 (D. Mass. Mar. 29, 2015) (“Stephanie C. I”). Upon remand from the First Circuit, the Court considers only whether, applying the de novo standard of review, Stephanie meets her burden to demonstrate coverage for Miles’s treatment at Gateway Academy (“Gateway”) under the group health benefit plan (the “Plan”). See Stephanie C. v. Blue Cross Blue Shield of Massachusetts HMO Blue, Inc., 813 F.3d 420, 429 (1st Cir. 2016) (“Stephanie C. II”).

         The Court solicited and reviewed the parties’ supplementary briefs addressing the application of the de novo standard of review in determining coverage of the claims. D. 57, 58. Having had the benefit of the parties’ previous briefing and oral argument, as well as supplemental briefing and a second oral argument, for the reasons stated below, the Court concludes that, even applying the de novo standard of review, Stephanie does not meet her burden to demonstrate coverage of the claims under the Plan and her motion for summary judgment, D. 27, is DENIED and BCBS’s motion for summary judgment, D. 24, is ALLOWED.

         II. Prior Rulings from the District Court and First Circuit

         In Stephanie C. I, this Court concluded that, based on the language of the Premium Account Agreement (“PAA”) and the Subscriber Certificate, BCBS is granted discretionary authority to determine eligibility for benefits under the Plan. See Stephanie C. I, 2015 WL 1443012, at *7. The Court rejected Stephanie’s arguments that increased scrutiny should be applied where the Court concluded there was no conflict of interest because BCBS is only “granted full discretionary authority to make decisions regarding the amount, form and timing of benefits and other claims-based decisions, not to make payments of claims out of plan assets.” See id. at *8 (citation and internal quotation marks omitted). The Court further concluded that there were no procedural irregularities to necessitate heightened scrutiny where BCBS provided Stephanie with a sufficient explanation for the denial of benefits as well as the entire claim file in advance of her appeal. See id. at *8-9. The Court, in applying the more deferential arbitrary and capricious standard of review, concluded that BCBS did not abuse its discretion in denying the claims. See id. at *9-12.

         On appeal, the First Circuit affirmed in part and vacated in part this Court’s decision. See Stephanie C. II., 813 F.3d at 423. The First Circuit affirmed the portion of this Court’s decision relating to the purported conflict of interest and procedural irregularities. Id. at 425-27. In vacating the Court’s judgment regarding BCBS’s denial of benefits, the First Circuit held that the language of the Subscriber Certificate was not sufficiently clear to grant discretionary authority to BCBS to determine eligibility benefits. Id. at 428. The First Circuit remanded the case to this Court only to reconsider BCBS’s denial of coverage by applying the de novo standard of review. Id. at 429.

         III. De novo Standard of Review

         In applying the de novo standard of review in an ERISA denial-of-benefits case, the Court “independently weigh[s] the facts and opinions in the administrative record to determine whether the claimant has met [her] burden” of demonstrating, by a preponderance of the evidence, coverage of claims under the applicable plan or policy. See Richards v. Hewlett-Packard Corp., 592 F.3d 232, 239 (1st Cir. 2010); Adele E. v. Anthem Blue Cross, No. 15-cv-01-DBH, 2016 WL 1732722, at *6 (D. Me. Apr. 28, 2016) (citation omitted); see also Wickman v. Nw. Nat. Life Ins. Co., No. 86-cv-1895-WF, 1989 WL 129240, at *2 (D. Mass. Oct. 23, 1989), aff’d sub nom. Wickman v. Nw. Nat. Ins. Co., 908 F.2d 1077 (1st Cir. 1990). Where the Court bases its review on the administrative record and ultimately decides coverage, “summary judgment is simply a vehicle for deciding the issue.” Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510, 517 (1st Cir. 2005). Essentially, the Court stands in the shoes of the policy administrator to determine whether its decision was correct. See Richards, 592 F.3d at 239 (citation omitted). In doing so, the Court gives “no deference to the administrator’s opinions or conclusions.” See Gross v. Sun Life Assur. Co. of Canada, 734 F.3d 1, 17 (1st Cir. 2013) (citation omitted).

         IV. Discussion

         As discussed in Stephanie C. I, “the terms of the Subscriber Certificate expressly state that benefits will not be provided for ‘services that are performed in educational, vocational, or recreational settings’ even if they ‘include therapeutic elements and/or clinical staff services as well as vocational, educational, problem solving, and/or recreational activities.’” Stephanie C. I, 2015 WL 1443012, at *10 (citation omitted).[1] Stephanie does not dispute that Gateway “offers, as a component of its comprehensive services, an accredited educational program for its patients, ” D. 33 ¶ 14; see id. ¶ 16. Although Stephanie disputes that Miles was admitted as a student, [2] id. ¶ 14, “Family Progress Notes” indicate that Stephanie discussed “Miles’s initial week at Gateway including school, ” AR 243. Additionally, Gateway refers to its patients as “students, ” see, e.g., AR 246 and “Individual Progress Notes” indicate that Miles received schooling, see AR 250. Applying the de novo standard of review and independently weighing the evidence in the record, Stephanie has not met her burden of demonstrating coverage under the Plan for Miles’s stay at Gateway where mental health services were provided to him in an educational setting. This basis alone forecloses coverage of the claims under the Plan. AR 58.

         Stephanie argues, however, that BCBS cannot rely on the educational limitation as a basis to deny the claims because such a limitation was not mentioned to Stephanie during the appeals process. See D. 32 at 9; D. 58 at 7-9.[3] Reviewing the record de novo, Stephanie does not meet her burden to demonstrate that BCBS failed to articulate the educational limitation to her. In her complaint, Stephanie acknowledged that BCBS informed Miles’s father that the Plan did not cover treatment that was provided “in a school setting.” D. 1 ¶ 66. Additionally, Stephanie does not contest BCBS’s assertion in its statement of material facts that “[o]n June 20, 2011, Blue Cross informed Miles’ father that the payment was a one-time exception” and that “the Plan did not cover treatment provided in a school setting, ” but challenges only the record citation BCBS provides (AR 214). See D. 33 ¶ 21. The Court, however, does not rely on the educational limitation alone in concluding that Stephanie has not met her burden in demonstrating coverage for the claims.

         Applying the de novo standard of review, Stephanie also has not met her burden in demonstrating that Miles’s treatment at Gateway was “medically necessary”-as defined in the Preferred Blue PPO Preferred Provider Deductible Subscriber Certificate (“Subscriber Certificate”)-and thus covered under the Plan. As discussed in Stephanie C. I, two psychiatrist reviewers, on behalf of BCBS, utilized the InterQual Criteria to determine whether Miles’s stay at Gateway was medically necessary to treat his condition. See Stephanie C. I, 2015 WL 1443012, at *10. Stephanie does not appear to contest the use of the InterQual Criteria in this regard. D. 58 at 3-6. The InterQual Criteria requires that Miles, at the time of admission to Gateway, meets the criteria for “Clinical Indications” and “Social Risks.” AR 189-90. The criteria for “Social Risks” includes criteria for “Risks” and “Level of Care, ” respectively, both of which must be satisfied. AR 190. Applying the de novo standard of review and independently weighing the evidence in the record, Stephanie fails to satisfy her burden to demonstrate that Miles’s condition met either aspect of the “Social Risks” criteria.

         The “Risks” criteria requires a reviewer to find, in part, a record of unsuccessful treatment within the year prior to admission. AR 190. Unsuccessful treatment is defined as (1) “lack of improvement of the patient’s symptoms and behaviors in prior treatment, ” or; (2) a patient’s “inability to complete an adequate trial of treatment provided by a licensed program or clinician.” AR 192 ¶ 18. Reviewing the record de novo, Stephanie has not met her burden to demonstrate that Miles’s three-month treatment at the Vantage Point of Aspiro (“Aspiro”)-a short term wilderness therapy program for teenagers, D. 33 ¶ 34-immediately prior to his admission to Gateway was “unsuccessful, ” considering the improvements he made. See AR 689-95; Stephanie C. I, 2015 WL 1443012, at *11. As to Miles’s “Emotional Regulation, ” Aspiro’s discharge report indicates that Miles “showed increasing ability to express himself and engage in emotional problem solving over time” and an “increasing ability to deal with frustration and disappointment.” AR 691. Regarding Miles’s “Behavior Regulation, ” the discharge report indicates that Miles had “developed a better ability [to] manag[e] his behaviors” and that “[h]e reduced his inappropriate talk and impulsive ...


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