Campbell v. Chevron Phillips Chemical Co., L.P., Civil Action No. 1:05-CV-0273.

CourtUnited States District Courts. 5th Circuit. United States District Court of Eastern District Texas
Citation587 F.Supp.2d 773
Decision Date15 August 2006
Docket NumberCivil Action No. 1:05-CV-0273.
PartiesAndrew W. CAMPBELL, M.D., Individually and d/b/a Medical Center for Immune & Toxic Disorders, Plaintiff, v. CHEVRON PHILLIPS CHEMICAL COMPANY, L.P., Medical Benefits Plan, Defendant.
587 F.Supp.2d 773
Andrew W. CAMPBELL, M.D., Individually and d/b/a Medical Center for Immune & Toxic Disorders, Plaintiff,
CHEVRON PHILLIPS CHEMICAL COMPANY, L.P., Medical Benefits Plan, Defendant.
Civil Action No. 1:05-CV-0273.
United States District Court, E.D. Texas, Beaumont Division.
August 15, 2006.

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Matthew Brian Probus, Wauson & Associates PC, Sugarland, TX, for Plaintiff.

Jennifer Lynn Anderson, Jones Walker Waechter Poitevent, Alia S. Wynne, Jones Walker, New Orleans, LA, for Defendant.

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MARCIA A. CRONE, District Judge.

Pending before the court is Defendant Chevron Phillips Chemical Company, L.P., Medical Benefits Plan's (the "Chevron Plan") Motion for Summary Judgment (# 71). The Chevron Plan seeks summary judgment on Plaintiff Andrew W. Campbell, M.D., individually and d/b/a Medical Center for Immune & Toxic Disorders's ("Dr.Campbell") claims that Aetna Life Insurance Company ("Aetna") abused its discretion in denying payment for medical services he provided to Theresa L. Freeman ("Mrs.Freeman") in violation of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1132 (2005) ("ERISA"). Having reviewed the pending motion, the submissions of the parties, the pleadings, and the applicable law, the court is of the opinion that the Chevron Plan's motion should be granted.

I. Background

Michael Freeman ("Mr.Freeman"), through his employment with Chevron Phillips Chemical Company, L.P., ("Chevron"), participated in the Chevron Phillips Chemical Company LP Medical Plan (the "Medical Plan"). The Medical Plan is a self-funded employee benefit plan, providing medical healthcare coverage to Chevron employees and their dependents. As Mr. Freeman's spouse, Mrs. Freeman qualifies as an eligible dependent under the terms of the Medical Plan. Aetna Life Insurance Company ("Aetna") provides claims administration services to the Medical Plan pursuant to an Administrative Services Only Agreement (the "Services Agreement"). Additionally, according to Defendant, Aetna acts "as fiduciary solely for benefit determinations and review of denied claims for benefits under ERISA" and has "complete and final discretionary authority to interpret the plans and [to] maintain control over the operation and administration of the plans."

Mrs. Freeman experienced a myriad of health problems, including pain in her lymph nodes, recurring respiratory problems, persistent cough, shortness of breath, tingling in her hands and fingers, and loss of balance. Mrs. Freeman's primary care physician referred her to Dr. Campbell, a medical provider outside of Aetna's network, who renders medical treatment and services for immune and toxicological disorders. According to Defendant, Dr. Campbell specializes in the detection and treatment of illnesses such as chronic fatigue syndrome and sick building syndrome.

The Chevron Plan claims that, before Mrs. Freeman's initial office visit with Dr. Campbell, Aetna received a telephone call attempting to verify her coverage under the Medical Plan. Defendant alleges that Aetna informed Dr. Campbell's office that Mrs. Freeman's medical coverage did not generally include out-of-network benefits for the services he was planning to provide. The Chevron Plan notes that because Aetna does not have a specialist within its network for the treatment of toxic and immune disorders, the Medical Plan allows for limited out-of-network claims with the understanding that benefit reimbursement is subject to the Medical Plan's coverage provisions and Aetna's review for medical necessity.

During her first office visit on August 9, 2001, Mrs. Freeman informed Dr. Campbell that she believed mold existed at her place of employment. After a physical examination and blood studies, Dr. Campbell diagnosed Mrs. Freeman with a "building related illness" attributed to toxic mold. According to Dr. Campbell, the test results indicated that Mrs. Freeman had "an abnormally low, natural killer cell activity which indicated a depressed immune

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system and had extraordinarily abnormal levels of immunoglobulin that fight a number of toxic molds, including stachybotrys, histoplasma, coccididides, candida, and pullularia pullulans." In an attempt to restore her immune system to normal levels, Dr. Campbell wrote Mrs. Freeman a prescription for intravenous immunoglobulin ("IVIG") infusion treatments.

Defendant alleges that, in connection with these services, Aetna received a telephone call from Gentiva Health Services ("Gentiva"), a participating provider within the Aetna network, seeking to verify Mrs. Freeman's coverage for home healthcare and monthly home IVIG infusion treatments. According to the Chevron Plan, Aetna advised Gentiva's representative that Mrs. Freeman's home healthcare was payable at 100%, subject to the Medical Plan's coverage provisions, including the determination of medical necessity of the prescribed treatments, and that any requested treatments required pre-certification by Aetna.

Mrs. Freeman continued to receive follow-up diagnostic services from Dr. Campbell and IVIG treatments from Gentiva between September 5, 2001, and July 15, 2003. Dr. Campbell submitted claims for benefits under the Medical Plan seeking reimbursement for the services he rendered. Aetna processed the claims submitted for Mrs. Freeman's diagnostic testing and paid benefits pursuant to its interpretation of the terms of the Medical Plan. Aetna denied a majority of the charges submitted by Dr. Campbell because it determined that the services he provided to Mrs. Freeman were not medically necessary and, thus, not covered by the Medical Plan.

Dr. Campbell initiated the appeals process via a written request to Aetna on June 17, 2002. Aetna's reimbursement decisions regarding Mrs. Freeman's diagnostic testing and treatment were reviewed by four medical professionals. Defendant maintains that after analyzing Mrs. Freeman's available medical records, Aetna's medical examiners concluded that the majority of the benefits requested by Dr. Campbell were not medically necessary, and therefore, were not covered under the Medical Plan. Dr. Campbell asserts that the denial of these reimbursements was arbitrary and capricious. Defendant contends that Aetna's benefits determination was legally correct under the terms of the Medical Plan and did not constitute an abuse of discretion.

In March 2005, the Freemans filed suit against Aetna, asserting state law claims arising out of Aetna's denial of benefits. On April 8, 2005, Aetna removed the case to this court on the basis of federal question jurisdiction. The Freemans subsequently amended their complaint to assert an ERISA claim, arguing that Aetna improperly denied medical benefits payable under the Medical Plan. The Freemans sought to recover benefits purportedly due them under the Medical Plan, to enforce their rights under the Medical Plan, and to clarify their rights to future benefits under the terms of the Medical Plan.

Aetna filed a third-party complaint against Dr. Campbell on September 1, 2005, seeking declaratory relief. On September 21, 2005, Dr. Campbell filed a counterclaim against Aetna. Dr. Campbell then filed cross-claims against the Freemans on December 6, 2005, for breach of contract. On January 6, 2006, Dr. Campbell filed a third-party complaint against the Chevron Plan seeking reimbursement for his testing and treatment of Mrs. Freeman. In accordance with joint stipulations filed by the parties, the court dismissed Dr. Campbell's counterclaim against Aetna, Dr. Campbell's cross-claims against the Freemans, Aetna's third-party claims against Dr. Campbell, and the Freemans'

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claims against Aetna. On June 15, 2006, the Chevron Plan filed the instant motion seeking summary judgment on all claims asserted by Dr. Campbell.

II. Analysis

A. Summary Judgment Standard

Rule 56(c) of the Federal Rules of Civil Procedure provides that summary judgment "shall be rendered forthwith if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." FED. R.Civ.P. 56(c). The party seeking summary judgment bears the initial burden of informing the court of the basis for its motion and identifying those portions of the pleadings, depositions, answers to interrogatories, admissions on file, and affidavits, if any, which it believes demonstrate the absence of a genuine issue of material fact. See Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986); Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247-48, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986); Warfield v. Byron, 436 F.3d 551, 557 (5th Cir.2006); Lincoln Gen. Ins. Co. v. Reyna, 401 F.3d 347, 349 (5th Cir.2005); Martinez v. Schlumberger, Ltd., 338 F.3d 407, 411 (5th Cir.2003); Terrebonne Parish Sch. Bd. v. Mobil Oil Corp., 310 F.3d 870, 877 (5th Cir.2002).

"A fact is `material' if it `might affect the outcome of the suit under governing law.'" Bazan v. Hidalgo County, 246 F.3d 481, 489 (5th Cir.2001) (emphasis in original) (quoting Anderson, 477 U.S. at 248, 106 S.Ct. 2505); see Cooper Tire & Rubber Co. v. Farese, 423 F.3d 446, 454 (5th Cir.2005); Harken Exploration Co. v. Sphere Drake Ins. PLC, 261 F.3d 466, 471 (5th Cir.2001); Merritt-Campbell, Inc. v. RxP Prods., Inc., 164 F.3d 957, 961 (5th Cir.1999); Burgos v. Southwestern Bell Tel. Co., 20 F.3d 633, 635 (5th Cir.1994). "Factual disputes that are irrelevant or unnecessary will not be counted." Anderson, 477 U.S. at 248, 106 S.Ct. 2505. "An issue is 'genuine' if it is real and substantial, as opposed to merely formal, pretended, or a sham." Bazan, 246 F.3d at 489 (emphasis in original). Thus, a genuine issue of material fact exists "if the...

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