Benjamin v. Oxford Health Ins., Inc., 3:16-cv-00408 (CSH)
Decision Date | 19 July 2018 |
Docket Number | 3:16-cv-00408 (CSH) |
Court | U.S. District Court — District of Connecticut |
Parties | AMY BENJAMIN, Plaintiff, v. OXFORD HEALTH INSURANCE, INC., Defendant. |
RULING ON DEFENDANT'S AND PLAINTIFF'S CROSS MOTIONS FOR SUMMARY JUDGMENT
In this action, Plaintiff Amy Benjamin ("Benjamin") brings suit against her insurer for denying coverage of residential treatment for a mental and/or behavioral health disorder. Plaintiff asserts that the denial was wrongful because Plaintiff was entitled to coverage for the care received, under the terms of her insurance policy, which is governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), and because Defendant insurance company failed to make a full and fair evaluation of her claims, or notify her of how to obtain such an evaluation, either at the time of her initial claim or at the time of her two administrative appeals.
Plaintiff's Motion for Summary Judgment [Doc. 64] asks this Court to find that Defendant Oxford Health Insurance, Inc. ("Oxford") violated ERISA by its denial of her claim, and to award Plaintiff reimbursement of her claimed medical expenses. Defendant has filed its own Motion for Partial Summary Judgment [Doc. 61], requesting this Court to remand the disputed claim back to Defendant Oxford, for an evaluation of medical necessity and subsequent reimbursement of Plaintiff's covered medical expenses (if any). This Ruling resolves these fully briefed cross-motions.
The uncontested facts summarized below are taken from the Rule 56(a)(1) and Rule 56(a)(2) statements filed by Plaintiff and Defendant in support of and opposition to the pending cross motions. See Docs. 62, 64-5, 67, 70.
During the relevant time period, July 24 to October 14, 2014, Plaintiff was enrolled as a beneficiary in the Techstyle Contract Fabrics Freedom PPO Plan, "the Plan," an employee benefit welfare plan. The Plan was fully insured by Defendant Oxford, which was authorized by the Plan to administer benefits and render claim determinations, pursuant to the Plan.
The Plan provides coverage for "Outpatient and Professional Services for Mental Health Care," including "inpatient mental health care services relating to the diagnosis and treatment of mental, nervous, and emotional disorders."
The Plan specifically excludes any care that is not Medically Necessary. Under the Plan, services are Medically Necessary only when:
Benjamin 43.1
A determination of Medical Necessity is made by the "Utilization Review" process. Benjamin 94. The Plan's subsection on Utilization Review provides procedures by which health services are reviewed for Medical Necessity before, during, or after the provision of those services. Id. at 94-96. These three procedures are called, respectively, the Preauthorization, Concurrent, and Retrospective Reviews. Id. The Plan also provides an appeals structure for covered Plan members who wish to contest an adverse benefits determination. Id. at 96-102. This structure includes first- and second-level internal appeals. Id.
The Plan provides that, to obtain full reimbursement for certain identified services, covered individuals must obtain "preauthorization." Preauthorization is defined, by the Plan, as "[a] decision by Us prior to Your receipt of a Covered Service . . . that the Covered Service . . . is Medically Necessary." Benjamin 39.
The Plan contains an Out-of-Network Benefits Rider which explains the details of obtaining preauthorization. Under the heading "Failure to Seek Preauthorization," that Rider provides that:
If You fail to seek Our Preauthorization for benefits subject to this section, We will pay an amount $500 less than We would otherwise have paid for the care, or We will pay only 50% of the amount We would otherwise have paid for the care, whichever results in a greater benefit for You. You must pay the remaining charges. We will pay the amount specified above only if We determine the care was Medically Necessary even though You did not seek Our Preauthorization. If We determine that the services were not Medically Necessary, You will be responsible for paying the entire charge for the service.
Benjamin 124. Hereinafter, this opinion will refer to this provision as the "Penalty Clause." The preauthorization requirement, and the Penalty Clause, apply to mental health services.
On July 11, 2014, Plaintiff called Oxford, and was provided with information regarding benefits and Preauthorization under the Plan.
On July 24, 2014, Plaintiff presented at Caron Renaissance ("Caron"), a facility that treats behavioral and mental health disorders, for treatment, and was admitted on an inpatient basis, for mental health treatment. She did not request Preauthorization prior to her admission.
On or about July 29, 2014, Defendant received a call from an individual who identified himself as "John" from Caron. Defendant provided John with information about coverage under the Plan.
On October 2, 2014, Plaintiff was discharged from Caron. Neither any application for Preauthorization nor any claim for coverage of the services she received from Caron between July 29 and October 2 was made during her inpatient stay.
On October 31, 2014, Plaintiff submitted a post-care claim to Oxford for the care she received from Caron between July 29 and October 2, 2014. No clinical records were submitted withthis claim.
Oxford denied Plaintiff's claim, citing to claim code D2, which provides,
Benjamin 228.
By letter dated February 24, 2015, Defendant issued an adverse benefit determination, in response to Plaintiff's appeal, reading in part:
Benjamin 236-37. The letter states that Defendant's Id.
On April 17, 2015, Plaintiff submitted a second-level appeal letter to Defendant. As grounds for reconsideration of Defendant's denial, she quoted the Penalty Clause from the Out-of-Network Rider, and argued "[t]herefore, a lack of pre authorization is not grounds for denying payment of these claims." Benjamin 257-58.
Benjamin 271-72 (emphasis in the original). At no...
To continue reading
Request your trial-
Meidl v. Aetna, Inc.
...Cayuga Med. Ctr. at Ithaca Prepaid Health Plan, 217 F.Supp.3d 608, 635 (N.D.N.Y. 2016) ; Benjamin v. Oxford Health Ins., Inc., No. 3:16-CV-00408 (CSH), 2018 WL 3489588, at *9 (D. Conn. July 19, 2018).Nor does the case law cited in Aetna's briefs provide the court with any basis for deviatin......