B v. Horizon Blue Cross Blue Shield Newjersey

• Decision Date: 25 August 2017
• Docket Number: Civil Action No.: 14-cv-1153
• Parties: RACHEL B, Plaintiff, v. HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY, Defendant.
• Court: U.S. District Court — District of New Jersey

RACHEL B, Plaintiff, v. HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY, Defendant.

Civil Action No.: 14-cv-1153

UNITED STATES DISTRICT COURT DISTRICT OF NEW JERSEY

August 25, 2017

NOT FOR PUBLICATION

OPINION

CECCHI, District Judge.

I. INTRODUCTION

This matter comes before the Court by way of Defendant Horizon Blue Cross Blue Shield of New Jersey's ("Defendant" or "Horizon") motion for summary judgment, see Fed. R. Civ. P. 56(a), against Plaintiff Rachel B. ("Plaintiff") (ECF No. 43); Plaintiff's cross-motion for summary judgment against Defendant (ECF No. 46); and Plaintiff's motion to determine the administrative record (ECF No. 47). The Court has considered the submissions made supporting and opposing the instant motions. The motions are decided without oral argument pursuant to Fed. R. Civ. P. 78(b).¹ For the reasons set forth below, Defendant's motion is GRANTED in part and DENIED in part; Plaintiff's cross-motion for summary judgment is GRANTED in part and DENIED in part; and Plaintiff's motion to determine the administrative record is DENIED.

The Court has jurisdiction pursuant to 28 U.S.C. § 1331.

II. BACKGROUND

The parties have submitted briefs, statements of facts pursuant to Local Civil Rule 56.1, declarations, and exhibits reflecting the following factual background.

Plaintiff brings this action under 29 U.S.C. § 1132(a)(1)(B) of the Employee Retirement Income Security Act of 1974 ("ERISA"), claiming Defendant wrongfully denied her benefits under an ERISA-covered health plan (the "Plan") under which she is a covered dependent.

A. Plaintiff's Health Plan

Plaintiff's Plan covers treatment furnished by a recognized health care provider that is medically necessary and appropriate. (Def.'s 56.1 ¶ 9). Defendant determines medical necessity and appropriateness "at its discretion" according to certain criteria.² (Id. ¶ 7).

Defendant contracted with Magellan Behavioral Health ("Magellan") to manage the Plan. (Id. ¶ 26; Pl.'s 56.1 ¶ 18 n.2). The Plan provides claimants an internal appeal process in which Defendant conducts a two-level internal review of denied claims. (Def.'s 56.1 ¶ 10). The Plan also provides an external appeal to an Independent Utilization Management Review Organization ("IURO"), selected by the New Jersey Department of Banking and Insurance ("DOBI"), for claimants who first exhaust the internal process. (Id. ¶ 10; Flynn Decl. Ex. A at HOR-197). If the IURO determines Defendant has deprived an insured of medically necessary treatment, it will inform Defendant and the insured of its determination of what medically necessary treatment the insured should receive. (Def.'s 56.1 ¶ 10). The IURO's treatment plan then becomes binding onHorizon and the insured, "except to the extent that other remedies are available to either party under state or federal law." (Flynn Decl. Ex. A at HOR-198). The Plan appears to be silent as to the binding effect on Defendant or an insured if the IURO upholds Defendant's denial of coverage.

B. Plaintiff's Hospitalization

Plaintiff has a history of an eating disorder and other mental health issues. On April 4, 2013, Plaintiff, then age 21, was admitted to the Oliver-Pyatt Center ("OPC") in Miami, Florida, for partial hospitalization treatment ("PHT") with overnight boarding. (Pl.'s 56.1 ¶ 7; Def.'s 56.1 ¶ 13). There, Plaintiff was diagnosed with "eating disorder not otherwise specified," anxiety disorder, attention deficit hyperactivity disorder, and depression. (Pl.'s 56.1 ¶ 8). When admitted, Plaintiff was five feet, three inches tall and weighed 98.6 pounds, well below what her doctors deemed to be her ideal body weight. (Id. ¶ 9). Plaintiff reported skipping meals and snacks, and purging four to five times per week. (Id. ¶ 10).

When Plaintiff was admitted at OPC, Defendant told Plaintiff and OPC that authorization was required for PHT. (Def.'s 56.1 ¶ 17). Defendant provided coverage for PHT at OPC from April 4 to April 29, 2013.³ (Id. ¶¶ 18, 21). On April 25, 2013, Defendant informed OPC and Plaintiff it had determined not to cover PHT after April 29 because only an intensive outpatient plan ("IOP") was medically necessary. (Id. ¶¶ 21-22). On Plaintiff's behalf, OPC appealed Defendant's denial of PHT for dates after April 29. (Id. ¶¶ 24-25). OPC did not have a discharge plan in place because neither of Plaintiff's parents were willing to take Plaintiff into their respective homes after discharge. (Id. ¶ 30). On May 3, 2013, after an expedited appeal and second level appeal, Defendant affirmed its denial of PHT as no longer medically necessary, butcovered Plaintiff's PHT for April 29 to May 2, 2013. (Id. ¶ 38). Defendant informed Plaintiff of this decision by letter dated May 3, 2013, in which Defendant stated, "We have approved continuation of coverage through 05/02/2013 to allow completion of your appeal request. Continuation of coverage from 05/03/2013 forward remains denied." (Flynn Decl. Ex. G-2).

C. External Appeal

On May 6, 2013, Plaintiff appealed Defendant's denial of PHT coverage to an IURO. (Def.'s 56.1 ¶ 39). The DOBI assigned the appeal to an entity called Permedion. (Flynn Decl. Ex. F at HOR-349). Dr. Lauren Ozbolt, Plaintiff's treating psychiatrist at OPC, submitted to Defendant a letter dated May 6, 2013 in support of the IURO appeal. (Green Decl. Ex. B at RachelB0920-22; Pl.'s 56.1 ¶ 50). This letter states the following:

It has become clear to staff that [Plaintiff] "under reports her symptoms and struggles." She has a very superficial understanding of her illness and often uses concepts in an inappropriate and inaccurate way. [Plaintiff's previously undiagnosed Pervasive Development Disorder] contributes to [Plaintiff's] inability to manage her distressing and ruminative eating disorder thoughts, as well as her inability to actively follow through . . . .

At this time, [Plaintiff] shows difficulty in maintaining her personal living in staff supported housing, and struggles with social interactions. . . . Should she step down to a lower level of care, it is extremely likely that her isolation will not improve, but worsen. Ability to maintain adequate social support is a self-care skill that [Plaintiff] is not capable of at this time. If [Plaintiff] were to discharge from PHP, it is clear that she would quickly decompensate in the manner that occurred after her discharge from [a previous treatment facility].

According to all parties who have evaluated [Plaintiff], and according to American Psychiatric Association criteria, [Plaintiff] requires support at and after all meals; she requires nutritional management which is medically monitored; she must have all meals and calorie intake monitored; she is at high risk for ongoing restricting and purging. Support at all meals is necessary in order to be able to continue to restore weight and also not return to her previous behaviors. . . .

[Plaintiff] has been working to build trust with the OPC treatment team and setting[.] [B]ecause of the high frequency of sessions, and the highly individualized treatment team approach[,] a disruption to her treatment would be highly destabilizing to her . . . . This would most certainly not result in progression toward recovery; rather it would create disruption and likely cause an exacerbation of depression and worsening of her eating disorder.

(Green Decl. Ex. B at RachelB0920-21).

On May 8, 2013, Permedion upheld Defendant's finding that PHT was no longer medically necessary. (Def.'s 56.1 ¶ 40). In a section labeled "Reviewer's Findings," Permedion noted that Plaintiff "has improved substantially during the course of her stay and there is no indication that she could not be safely and effectively treated at a less intensive level of care." (Flynn Decl. Ex. F at HOR-359). It further stated "[t]he information submitted for review in sum does not indicate why she could not be safely and effectively managed in the context of an IOP." (Id.). Permedion found "[t]here is no indication that this enrollee is partially motivated" in her treatment, and "nothing in the records submitted to indicate that the enrollee has not been adherent to the dietary plan or that there has been any other problem behavior." (Id. at HOR-360). Permedion's report does not address Dr. Ozbolt's letter except to list it as a document it reviewed.⁴ (Id. at HOR-358-60). Defendant informed Plaintiff of its intent to abide by Permedion's decision in a letter dated May 9, 2013, stating: "the request for partial hospitalization from 5/03/13 forward at Oliver Pratt [sic] Center has been denied and will remain denied. Please be advised that this is the final level of appeal available to you." (Flynn Decl. Ex. G-3).

D. Plaintiff's Continued Treatment at OPC

Notwithstanding Defendant's denial of PHT from May 3 onward, Plaintiff continued PHT at OPC until she was discharged on July 3, 2013 and transitioned to an IOP. (Pl.'s 56.1 ¶¶ 60, 67). During her stay at OPC, she continued to struggle with her eating disorder and other psychological conditions. (Id. ¶¶ 61-66). Plaintiff submitted claims to Defendant seeking coverage of Plaintiff's PHT taking place on May 3, 9, 10, 11, and 12, 2013. (Def.'s 56.1 ¶ 43). Plaintiff submitted some of these claims even after Defendant had informed Plaintiff in the May 9 letter of its decision to abide by Permedion's final determination. (Id. ¶¶ 43-44). Plaintiff never submitted claims for PHT to Defendant for dates after May 12, 2013. (Id. ¶ 45).

III. LEGAL STANDARD

Summary judgment is appropriate if the "depositions, documents, electronically stored information, affidavits or declarations, stipulations . . . admissions, interrogatory answers, or other materials" demonstrate that there is no genuine issue as to any material fact, and, construing all facts and inferences in a light most favorable to the non-moving party, "the moving party is entitledto a judgment as a matter of law." Celotex Corp. v. Catrett, 477 U.S. 317, 330 (1986); Pollock v. Am. Tel. & Tel. Long Lines, 794 F.2d...