Brazil v. Office of Pers. Mgmt.
| Decision Date | 28 March 2014 |
| Docket Number | Case No. 12–cv–02898–WHO |
| Citation | 35 F.Supp.3d 1101 |
| Court | U.S. District Court — Northern District of California |
| Parties | Amelia Byrnes Brazil, Plaintiff, v. Office of Personnel Management, Defendant. |
Elizabeth Katherine Green, Lisa Sue Kantor, Kantor & Kantor LLP, Northridge, CA, for Plaintiff.
Chi Soo Kim, United States Attorney's Office, Sacramento, CA, for Defendant.
ORDER ON CROSS–MOTIONS FOR SUMMARY JUDGMENT
Re: Dkt. No. 48
Plaintiff Amelia Byrnes Brazil received medically necessary mental health treatment at a residential facility. Her federal health insurance plan denied coverage because the plan excluded coverage for residential treatment centers, and so she is seeking redress here. Both California and the United States have passed mental health parity laws requiring that treatment limitations for mental health benefits are no more restrictive than those for medical and surgical benefits, but federal law excludes federal insurance plans from their scope. The question I must decide is whether Brazil can overcome defendant Office of Personnel Management's (“OPM”) assertions of sovereign immunity and preemption in order to address the merits of her claim. Because federal law does not allow the relief Brazil seeks, her motion for summary judgment is DENIED and OPM's motion for summary judgment is GRANTED.
At all times relevant in this matter, Brazil was enrolled in the Federal Employees Health Benefits Program's Blue Cross and Blue Shield Service Benefit Plan (the “Plan”). OPM0002; Opp'n (Dkt. No. 51) 2. The Plan is administered in California by Blue Shield of California (“BSC”). It is “fee for service ... with a preferred provider organization” and is “[s]ponsored and administered by: The Blue Cross and Blue Shield Association and participating Blue Cross and Blue Shield Plans.” OPM 0048. The “[m]ental health and substance abuse benefits” do not include “[s]ervices performed or billed by ... residential treatment centers.” OPM0138, OPM0140.
On August 5, 2011, Brazil was hospitalized for 15 days at the Lucille Packard Children's Hospital for anorexia nervosa
. OPM0013–14. All the physicians involved in Brazil's care agreed that she needed residential treatment. OPM0014. While the hospitalization addressed “the most immediate physical threats” to Brazil, it did not address “the underlying causes.” OPM0014. Brazil's father wrote to BSC that “without sustained and sophisticated treatment in a residential facility, those underlying causes would remain completely unaddressed,” and Brazil “would continue to suffer anorexia nervosa indefinitely, likely necessitating additional hospitalizations and multiple calls on other health care providers.” OPM0014. The physicians and Brazil's therapist, in consultation with her father, identified Monte Nido Vista Residential Center, in Agoura Hills, California, as the residential treatment program that best fits Brazil's medical needs and psychiatric circumstances. OPM0014.
Brazil entered Monte Nido Vista on August 23, 2011. OPM0015. On the same day, Brazil requested pre-certification from BSC for admission to Monte Nido Vista. OPM0002. BSC denied the request and told Brazil's father that his policy provided no benefits for residential treatment. OPM0015; OPM0022. Brazil's father contacted BSC to appeal the denial and “explained that the residential treatment at Monte Nido was a medical necessity,” but the BSC representative told him “that there was nothing to appeal and no point in purporting to initiate an appeal process—because the policy simply provided no benefit for residential treatment for this condition.” OPM0015. BSC therefore denied the request.
On August 29, 2011, Brazil's father submitted to BSC a claim for reimbursement for expenses he had and was going to incur for services being rendered to Brazil. OPM0013–16. Brazil's father cited a decision by the United States Court of Appeals for the Ninth Circuit, Harlick v. Blue Shield of California, 656 F.3d 832 (9th Cir.2011), withdrawn and superseded on denial of reh'g en banc, 686 F.3d 699 (9th Cir.2012), which he argued held that BSC was obligated to pay for treatment in a virtually identical case. OPM0016. On September 1, 2011, BSC again denied coverage, citing the Plan brochure as stating that services provided by “residential treatment centers” are not covered. OPM0020.
On September 1, 2011, Brazil's father responded to BSC, asking why it was not bound by Harlick . OPM0010. On September 28, 2011, BSC responded, stating that “Title 5 United States Code section 8902(m)(1) states that Plans participating with the FEHBP (Federal Employee Health Benefit Program) are exempt from regulation by state and local statute.” OPM0008. BSC also informed Brazil that she may ask OPM to review the claim dispute and explained the process for doing so. OPM0007–08.
On October 11, 2011, Brazil's father filed an appeal on her behalf to OPM. OPM0027. On November 3, 2011, OPM affirmed BSC's denial of the claim, asserting that the Plan explicitly does not cover services performed by residential treatment centers or their staff. OPM0026. OPM stated that “we are not disputing that your daughter needed this service for her medical condition,” but that the Plan did not cover the service. OPM0025–26. The letter also stated that “you do retain the right to file suit against the Office of Personnel Management in Federal court.” OPM0026.
On November 3, 2011, OPM informed Brazil that she exhausted the administrative remedies for appealing the denial of benefits. OPM0026. On June 4, 2012, Brazil filed this action. Dkt. No. 1. The First Amended Complaint (“FAC”) seeks (1) damages “in a specific sum to be proved at trial ... a sum that exceeds “$100,000” for violation of the Federal Employees Health Benefits Act of 1959, 5 U.S.C. §§ 8901 et seq. ; (2) a declaration that the Plan violates California's Mental Health Parity Act, Cal. Health & Safety Code § 1374.72, Cal Ins. Code § 10144.5 ; and (3) a declaration that the Plan violates the federal Mental Health Parity and Addiction Equity Act, 42 U.S.C. § 300gg–26, 29 U.S.C. § 1185a. In addition, the FAC seeks “an Order enjoining the Plan and the Defendant from continuing to incorporate into the insurance policies they provide or authorize any blanket exclusion of coverage for medically necessary residential treatment for anorexia nervosa
.” The FAC also seeks attorney's fees under the Equal Access to Justice Act, 28 U.S.C. § 2412, and costs.
Brazil filed this motion for summary judgment on November 18, 2013, Dkt. No. 48.1 OPM responded and made a cross- motion for summary judgment. Dkt. No. 51. A hearing was held on January 8, 2014. Dkt. No. 58.
Summary judgment is proper “if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). The moving party bears the initial burden of demonstrating the absence of a genuine issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). The moving party, however, has no burden to disprove matters on which the non-moving party will have the burden of proof at trial. The moving party need only demonstrate to the court “that there is an absence of evidence to support the non[-]moving party's case.” Id. at 325, 106 S.Ct. 2548.
Once the moving party has met its burden, the burden shifts to the non-moving party to “designate specific facts showing a genuine issue for trial.” Id. at 324, 106 S.Ct. 2548 (quotation marks omitted). To carry this burden, the non-moving party must “do more than simply show that there is some metaphysical doubt as to the material facts.” Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586, 106 S.Ct. 1348, 89 L.Ed.2d 538 (1986). “The mere existence of a scintilla of evidence ... will be insufficient; there must be evidence on which the jury could reasonably find for the [non-moving party].” Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 252, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). In deciding a summary judgment motion, the court must view the evidence in the light most favorable to the non-moving party and draw all justifiable inferences in its favor. Id. at 255, 106 S.Ct. 2505.
Kokkonen v. Guardian Life Ins. Co. of Am., 511 U.S. 375, 377, 114 S.Ct. 1673, 128 L.Ed.2d 391 (1994). A federal court must always have subject matter jurisdiction to hear a case. The burden of establishing jurisdiction rests on the party asserting it. Id.
Sovereign immunity and subject matter jurisdiction have a “murky” and “confusing relationship.” Powelson v. U.S., By & Through Sec'y of Treasury, 150 F.3d 1103, 1104 n. 1 (9th Cir.1998). Sovereign immunity is “a defense to an action against the United States”; it is also a “jurisdictional bar.” Id. (citation omitted). “Sovereign immunity is grounds for dismissal independent of subject matter jurisdiction.” Id. Accordingly, “[i]n an action against the United States, in addition to statutory authority granting subject matter jurisdiction, there must be a waiver of sovereign immunity.” Arford v. United States, 934 F.2d 229, 231 (9th Cir.1991). “A statute may create subject matter jurisdiction yet not waive sovereign immunity.” Powelson, 150 F.3d at 1105.
The Federal Employees Health Benefits Act of 1959 (“FEHBA”), 5 U.S.C. § 8901 et seq., “establishes a comprehensive program of health insurance for federal employees.” Empire Healthchoice Assur., Inc. v. McVeigh, 547 U.S. 677, 682, 126 S.Ct. 2121, 165 L.Ed.2d 131 (2006) (“Empire II ”). The Act authorizes OPM to contract with private insurers to offer healthcare plans to federal employees and their...
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