United States District Court, D. Massachusetts
MEMORANDUM AND ORDER ON PLAINTIFF'S MOTION
REGARDING THE RECORD FOR JUDICIAL REVIEW
Dennis Saylor, IV United States District Judge.
an action for benefits under the Employee Retirement Income
Security Act of 1974 (“ERISA”), 29 U.S.C.
§§ 1001 et seq.
Addie Fisher contends that defendant Harvard Pilgrim Health
Care of New England, Inc. (“HPHC”) failed to pay
medical benefits she was owed under her health plan.
Specifically, she challenges HPHC's decision to stop
paying for treatment relating to her eating disorder on the
ground that it was not medically necessary.
has provided a proposed record for judicial review. Fisher
contends that the record is deficient and should include
certain additional documents. Because Fisher has not
satisfied her burden to expand the record beyond the
documents available to the decisionmaker, the motion will be
following facts are set forth as alleged in the complaint and
in the partial record for judicial review filed with the
Court (“P.R. ”).
Fisher is a young woman with a history of bulimia nervosa.
(Compl. ¶ 6). Fisher is covered by health insurance from
HPHC through a health plan sponsored by her father's
employer. (Id. ¶ 3). The claims administrator
for HPHC is United Behavioral Health (“UBH”).
(Id. ¶ 10).
28, 2015, Fisher was admitted to Oliver Pyatt Centers, a
residential treatment facility that specializes in eating
disorders. (Id. ¶ 7). HPHC paid for
Fisher's treatment at Oliver Pyatt for approximately two
months. (Id. ¶ 9). On July 30, 2015, UBH
informed Fisher that it would stop paying for residential
treatment on July 31, 2015. (Id. ¶ 10).
then requested coverage for “partial
hospitalization” at Oliver Pyatt beginning August 1,
2015. (P.R. 95-96). UBH denied that claim on August 4, 2015,
on the ground that the requested level of care was not
medically necessary, and offered instead to cover outpatient
treatment. (P.R. 99-100, 126-28). Fisher appealed that
decision. (P.R. 115-17). On August 7, 2015, HPHC upheld its
decision to deny benefits. (P.R. 201-04). Fisher continued to
receive treatment at Oliver Pyatt until January 8, 2016, but
her family paid for the treatment until she stepped down to
outpatient care on October 6, 2015.
filed this action on July 3, 2017. HPHC has provided her
counsel with a proposed record for judicial review, but the
parties have been unable to agree on the proper contents of
that record. On May 22, 2018, Fisher filed the present
motion. She seeks an order that the record for judicial
review should include the following documents:
(1) All internal claim or utilization review notes by HPHC or
UBH pertaining to the treatment received by plaintiff between
May 28, 2015, and January 8, 2016, the dates of
plaintiff's stay at Oliver Pyatt;
(2) All communications between HPHC and/or UBH, on one hand,
and Oliver Pyatt, on the other, between May 28, 2015, ...