Andrews-Clarke v. Travelers Inc. Co.
| Citation | 984 F.Supp. 49 |
| Decision Date | 30 October 1997 |
| Docket Number | Civil Action No. 97-10191-WGY. |
| Parties | Diane ANDREWS-CLARKE, Individually and as Next Friend of the Estate of Richard J. Clarke and Next Friend of Diane Clarke, a minor child, and Lacey Clarke, a minor child, and Carly Clarke, a minor child, and Justin Clarke, a minor child, Plaintiff, v. TRAVELERS INSURANCE COMPANY; MetraHealth Insurance Company; United Health Care Insurance Company; TAO, Inc.; Greenspring of Eastern Pennsylvania; St. Joseph Hospital, Baldpate Hospital: and Southern New Hampshire Medical Center, Defendants. |
| Court | U.S. District Court — District of Massachusetts |
Richard J. Leonard, Haverhill, MA, for Diane Andrews-Clarke.
M. Therese Roche, Roche, Heifetz, Murphy & Wholley, Boston, MA, Michael B. O'Shaughnessy, Claire W. Rouillard, Robert J. Meagher, McDonough & O'Shaughnessy, Manchester, NH, for St. Joseph's Hosp.
William J. Davenport, Bloom & Buell, Boston, MA, for Baldpate Hosp.
Michael A. Pignatelli, Rath, Young & Pignatelli, P.A., Nashua, NH, for Southern New Hampshire Medical Center.
Joan O. Vorster, Mirick, O'Connell, DeMallie & Lougee, Worcester, MA, Scott Kirschbaum, Adorno & Zeder, Miami, FL, for Travelers Ins. Co., MetraHealth Ins. Co. and United Health Care Ins. Co.
Mark E. Cohen, Brian C. Duffey, McCormack & Epstein, Boston, MA, Susan Hughes Banning, James P. Warner, Hemenway & Barnes, Boston, MA, Arthur N. Lerner, David Florin, Beth M. Kramer, David W. O'Brien, Michaels, Wishner & Bonner, Washington, DC, for TAO, Inc.
Susan Hughes Banning, James P. Warner, Hemenway & Barnes, Boston, MA, Arthur N. Lerner, David Florin, Beth M. Kramer, David W. O'Brien, Michaels, Wishner & Bonner Washington, DC, for Greenspring of Eastern Pennsylvania.
Surveys show many people think the insurance industry's drive to cut costs has reduced dramatically the overall quality of health care, limiting not only their access to the best doctors and hospitals but also putting such time and financial strain on physicians that they can't possibly provide first-rate treatment....1 Hospital officials acknowledged that the cuts on hospital budgets have been steep and swift, occurring mostly because health insurers have scaled back the amount they reimburse hospitals to care for patients. As a result, hospitals are under pressure to send patients home sooner and sicker.2
Here's what's happening; support for training doctors is dwindling, and research is under great financial pressure. The quality of delivered health care services is being squeezed, inexorably, by insurers who insist on paying less and less, because that's what their corporate clients insist on; financial incentives are being provided to reward "doing less"; fewer Americans have access to health insurance institutions.
Dr. Lowell E. Schnipper, M.D.3
Here's what happened in this case.4 Richard J. Clarke and his wife, Diane Andrews-Clarke, lived in Haverhill, Massachusetts, with their four young children, Deanna, Lacey, Carly, and Justin. Diane Andrews-Clarke, an employee of AT & T,5 maintained a family health insurance policy with Travelers Insurance Co.6 through her AT & T employee benefit plan.7 Her husband and children were named beneficiaries of that policy.
Richard Clarke drank to excess. On April 22, 1994, Dr. Smita Patel admitted Richard Clarke to St. Joseph Hospital in Nashua, New Hampshire, for alcohol detoxification and medical evaluation. St. Joseph Hospital contacted Greenspring,8 the utilization review provider9 that must pre-approve treatment under the terms of Clarke's health plan, regarding Clarke's admission. Greenspring authorized only a five day hospital stay for detoxification. Despite the fact that the Travelers' insurance policy held by Andrews-Clarke specifically stated that each insured beneficiary is entitled to at least one thirty day inpatient rehabilitation program per year, Greenspring refused to approve Clarke's enrollment in a thirty day inpatient alcohol rehabilitation program.
After this five day hospital stay, Clarke was discharged from St. Joseph Hospital with a diagnosis of alcohol dependence, alcohol withdrawal symptoms, elevated liver function, and low hemoglobin. He remained alcohol-free for twenty-five days, but then resumed drinking. On September 12, 1994, he voluntarily admitted himself to Baldpate Hospital in Georgetown, Massachusetts, seeking help to stop drinking. Although aware both of Clarke's medical condition and the clear terms of the Travelers' insurance policy, Greenspring refused to authorize more than eight days of inpatient treatment. Baldpate discharged Clarke on September 20, 1994.
Less than twenty-four hours later, Clarke drank a substantial amount of alcohol, ingested cocaine, swallowed a handful of prescription drugs, and attempted to commit suicide by locking himself in the garage with the car engine running. His wife saved his life, breaking through the garage door to find him slumped on the floor. She shut off the car engine and dialed 911. Although Clarke had no detectable pulse or respiration when the ambulance arrived, the paramedics were able to revive him. Clarke was then flown to Henrietta Goodall Hospital in Sanford, Maine, where he was placed in a hyperbaric chamber and successfully treated for carbon monoxide poisoning.
By now, it was tragically apparent to everyone but Travelers and its agent, Greenspring, that Clarke was a danger to himself and perhaps others. After conducting a commitment hearing,10 the Haverhill District Court so found, and ordered Clark committed to a thirty-day detoxification and rehabilitation program. The court referred the issue of Clarke's placement to the Court Clinic, which in turn sought Greenspring's approval for an insured admission to a private hospital. When Greenspring—despite the fact that enrollment in a thirty-day inpatient detoxification program is a defined benefit of the Travelers insurance policy—incredibly refused to authorize such a private admission, the court ordered Clarke committed to the Southeastern Correctional Center at Bridgewater for his detoxification and rehabilitation.11
Clarke's life now spiralled inexorably down and out of control. While a patient at Bridgewater, he was forcibly raped and sodomized by another inmate in his unit. He received little in the way of therapy or treatment. After his release from Bridgewater on October 25, 1994, he made his way back to Haverhill where his wife and four minor children still lived. Diane Andrews-Clarke told Clarke that he could return to the marital home only if he remained sober. Unable to do so without hospitalization, Clarke began a three-week drinking binge.
After an episode of heavy drinking on November 10, 1994, Clarke was placed in protective custody by the Pelham, New Hampshire, police. Later that day, he was admitted to the Southern New Hampshire Medical Center in full respiratory arrest with a blood alcohol level of .380 and a head injury. Southern New Hampshire Medical Center made no effort to treat Clarke's alcoholism and did not seek to obtain a detoxification admission at any other facility. Clarke spent the night sleeping on a stretcher because it was too cold to discharge him and there were no beds available in area shelters. He was released the next morning.
Upon leaving Southern New Hampshire Medical Center, Clarke purchased a six-pack of Meisterbrau beer, which he immediately began to consume. At 3:06 a.m. on November 12, 1994, the Pelham, New Hampshire, police discovered Clarke's body in a parked car, with a garden hose extending from the tailpipe to the passenger compartment. Clarke, age forty-one, sat lifeless in the front seat, clasping a sixteen ounce beer can in his right hand. He was pronounced dead at the scene.
Subsequent to Clarke's death, Diane Andrews-Clarke commenced this action against Travelers and Greenspring in the Superior Court of the Commonwealth of Massachusetts sitting in and for the County of Essex, individually and as administratrix of Clarke's estate and as next friend of their four minor children.12 Andrews-Clarke asserts that her husband's death was the direct and foreseeable result of the improper refusal of Travelers and its agent Greenspring to authorize appropriate medical and psychiatric treatment during Clarke's repeated hospitalizations for alcoholism in 1994. She brought claims against them for breach of contract, medical malpractice, wrongful death, loss of parental and spousal consortium, intentional and negligent infliction of emotional distress, and specific violations of the Massachusetts consumer protection laws.13
Travelers and Greenspring promptly removed her case to this Court14 and then, just as promptly, asked this Court to throw her out without hearing the merits of her claim.15
This, of course, is ridiculous. The tragic events set forth in Diane Andrews-Clarke's Complaint cry out for relief. Clarke was the named beneficiary of a health insurance policy offered through an employee benefit plan. That policy expressly provided coverage for certain medical and psychiatric treatments, including enrollment in a thirty-day inpatient alcohol detoxification and rehabilitation program. Doctors at several hospitals, and even the courts of the Commonwealth of Massachusetts, determined that Clarke was in need of such treatment, but the insurer and its agent, the utilization review provider, repeatedly and arbitrarily refused to authorize it. As a consequence of their failure to preapprove —whether willful, or the result of negligent medical decisions made during the course of utilization review—Clarke never received the treatment he so desperately required, suffered horribly, and ultimately died needlessly at age forty-one.
Under traditional notions of justice, the harms alleged — if true — should entitle Diane Andrews-Clarke to some legal remedy on behalf of herself and her children against Travelers and Greenspring. Consider just one...
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