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Fisher v. Harvard Pilgrim Health Care of New England, Inc.

United States District Court, D. Massachusetts

July 13, 2018

ADDIE FISHER, Plaintiff,
v.
HARVARD PILGRIM HEALTH CARE OF NEW ENGLAND, INC., Defendant.

          MEMORANDUM AND ORDER ON PLAINTIFF'S MOTION REGARDING THE RECORD FOR JUDICIAL REVIEW

          F. Dennis Saylor, IV United States District Judge.

         This is an action for benefits under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq.

         Plaintiff 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.

         HPHC 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 denied.

         I. Background

         A. Factual Background

         The following facts are set forth as alleged in the complaint and in the partial record for judicial review filed with the Court (“P.R. ”).

         Addie 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).

         On May 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).

         Fisher 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.

         B. Procedural Background

         Fisher 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, ...

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