Chipman v. Cigna Behavioral Health, Inc.
| Decision Date | 14 August 2020 |
| Docket Number | Civil Action No. 19-456 (TJK) |
| Citation | 480 F.Supp.3d 174 |
| Parties | Robert CHIPMAN, Plaintiff, v. CIGNA BEHAVIORAL HEALTH, INC. et al., Defendants. |
| Court | U.S. District Court — District of Columbia |
Denise Marie Clark, Clark Law Group, PLLC, Washington, DC, for Plaintiff.
Christopher E. Humber, Ogletree, Deakins, Nash, Smoak & Stewart, P.C., Washington, DC, Sean P. Nalty, Pro Hac Vice, Ogletree, Deakins, Nash, Smoak & Stewart, P.C., San Francisco, CA, for Defendants.
Robert Chipman alleges that his health insurance plan administrator, Cigna, improperly denied coverage for residential mental health treatment for his dependent. Cigna denied that coverage after determining that it was not medically necessary under Chipman's health insurance plan. After exhausting Cigna's internal review process, Chipman filed this suit. Cigna moved for summary judgment, but Chipman failed to oppose. Reviewing for abuse of discretion, the Court finds that Cigna's determination was reasonable. As a result, it will grant Cigna's motion.
Chipman sues three defendants: his employer, Merkle Group Inc. ("Merkle"); his health insurance plan administrator, Cigna Behavioral Health, Inc. ("Cigna"); and his health insurance plan itself, Merkle Group Inc. Open Access Plus Medical Benefits Plan ("the Plan"). As a Merkle employee, Chipman is a member of the Plan, a self-funded group health plan sponsored by Merkle and administered by Cigna for the benefit of Merkle employees and their dependents. ECF No. 6 ("Am. Compl.") ¶ 6. Incident to Chipman's employment with Merkle, his dependent ("Dependent") received health coverage under the Plan. Id. ¶ 7.
Chipman's Plan provides coverage for services "to the extent that [they] are recommended by a Physician, and are Medically Necessary for the care and treatment of an Injury or a Sickness, as determined by Cigna." ECF Nos. 23-1 to 23-6 ("AR") at 2095.1 Services are "medically necessary" when they are "required to diagnose or treat an illness, injury, disease or its symptoms; in accordance with generally accepted standards of medical practice; clinically appropriate in terms of type, frequency, extent, site and duration; not primarily for the convenience of the patient, Physician or other health care provider; and rendered in the least intensive setting that is appropriate for the delivery of the services and supplies." Id. at 2126.
Dependent began struggling with mental health and behavioral issues in 2015. Id. at 343; see also Am. Compl. ¶ 18. After being admitted to several hospitals and attending various programs to treat mental health issues, Dependent was admitted in late 2016 to Catalyst RTC LLC ("Catalyst"), a facility in Utah "licensed to provide Residential Treatment for 26 Adult and Youth Clients Ages 13 to 18." AR at 1357; see also Am. Compl. ¶¶ 19–29, 32–35. Soon after, Chipman began filing claims for coverage by submitting medical records and reports to Cigna for a retrospective review. AR at 1897; see also Am. Compl. ¶ 42. Chipman's claims cover two separate periods during which Dependent was treated at Catalyst. The first period covers treatment from January to May 2017, AR at 1897–1901, and the second covers treatment from May 2017 to July 2018, id. at 1903–07.
Dr. Karl Sieg, a board-certified psychiatrist, conducted Cigna's initial "level-one" review for the claim covering the first treatment period. Id. at 1897–1901. He reviewed "information submitted by [the] provider and the terms of [Chipman's] benefit plan." Id. at 1873. He found that Dependent's symptoms and behaviors did not "require[ ] this intensity of service for safe and effective treatment," and that Dependent's admission to Catalyst "appear[ed] to be primarily for the purpose of providing a safe and structured environment." Id. ; see also Am. Compl. ¶ 43. Dr. Sieg also determined that even if residential treatment had been necessary, the Plan would still not have covered the treatment Catalyst was providing. AR at 1873–74; see also Am. Compl. ¶ 43. Based on this review, Cigna denied coverage. AR at 1874; see also Am. Compl. ¶ 43.
Chipman both appealed this denial and filed another, separate claim for Dependent's second treatment period at Catalyst. AR at 2224, 2259. As for the second treatment period, Dr. Liebe Gelman, another board-certified psychiatrist, conducted the level-one review of "the information submitted by [the] provider and the terms of [Chipman's] benefit plan." Id. at 1403; see also id. at 1903–07. Like Dr. Sieg before him, Dr. Gelman found that Dependent's treatment from May 2017 to July 2018 at Catalyst was not medically necessary. Id. at 1907. Specifically, Dr. Gelman concluded among other things that "[l]ess restrictive levels of care were available for safe and effective treatment." Id.
Finally, shortly after Dr. Gelman finished his first-level review of Chipman's claims for Dependent's second treatment period, Dr. Mohsin Qayyum, also a board-certified psychiatrist, conducted a second-level review of Cigna's decision to deny coverage for both treatment periods. Id. at 1907–10. After reviewing "the available clinical information received initially and with [the] appeal," Dr. Qayyum affirmed Cigna's decision to deny coverage for both periods.2 Id. at 1394–95. He agreed with the level-one reviewers that Dependent's symptoms did not show that the treatment at Catalyst was medically necessary given the Plan's criteria. Id. at 1395; see also Am. Compl. ¶ 45. He also found that Dependent's admission to Catalyst "appear[ed] to be primarily for the purpose of providing a safe and structured environment," and that "[l]ess restrictive levels of care were available for safe and effective treatment." AR at 1395; see also Am. Compl. ¶ 45. As a result, Cigna upheld its denial of coverage for both periods. AR at 1394; see also Am. Compl. ¶ 45.
After receiving letters detailing Dr. Gelman and Dr. Qayyum's findings, Chipman requested an external review of all the first- and second-level reviews to date from Cigna's Independent Review Organization ("IRO"). AR at 1415; see also Am. Compl. ¶ 46. The IRO, which is not "connected or related to [Cigna] in any way," AR at 1418, provides an independent review of Cigna's decisions, and the IRO's decisions are binding upon Cigna, id. at 1397. The IRO reviewer—an independent, board-certified psychiatrist with subcertification in Child & Adolescent Psychiatry, id. at 1892—evaluated all the "relevant medical documents utilized in [Cigna's] review process," id. at 1863, as well as more information submitted by Chipman, including treatment records for the months immediately preceding Dependent's admission to Catalyst, id. at 1868–72; see also id. at 1889–90 (). The IRO agreed with Cigna's determinations, concluding that the residential treatment "was not medically necessary," as "[t]here were alternative, less intensive approaches that could provide safe and effective treatment during this time." Id. at 1890–91; see also Am. Compl. ¶ 47.
Chipman then filed this suit under the Employee Retirement Income Security Act of 1974 (ERISA), Pub. L. No. 93-406, 88 Stat. 829. Section 502(a)(1)(B) of ERISA allows plan participants or beneficiaries "to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132(a)(1)(B).3 Chipman claims that Dependent's treatment at Catalyst should have been covered. Am. Compl. ¶¶ 6, 49–50. Earlier this year, Defendants moved for summary judgment, ECF No. 26, arguing that the Court should uphold Cigna's decision because it was reasonable, ECF No. 26-1 ("MSJ") at 1–2. But Chipman—who is represented by counsel—failed to respond, despite having been granted two extensions of time to do so. See Minute Orders of Apr. 15, 2020, and Apr. 23, 2020.4
Summary judgment is usually appropriate "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). "But in an ERISA case, when the decision to grant or deny benefits is reviewed for abuse of discretion, a motion for summary judgment is merely the conduit to bring the legal question before the district court and the usual tests of summary judgment, such as whether a genuine dispute of material fact exists, do not apply." James v. Int'l Painters & Allied Trades Indus. Pension Plan , 844 F. Supp. 2d 131, 141 (D.D.C. 2012), aff'd , 738 F.3d 282 (D.C. Cir. 2013) (cleaned up).
Under ERISA, a denial of benefits is subject to de novo review unless—as is often the case—the benefit plan gives its fiduciaries discretionary authority to determine eligibility for benefits or to construe the terms of the plan. Firestone Tire & Rubber Co. v. Bruch , 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). When a plan grants that discretion, "a deferential standard of review [is] appropriate," id. at 111, 109 S.Ct. 948, and the question before the court is whether a decision to deny benefits was reasonable, Block v. Pitney Bowes Inc. , 952 F.2d 1450, 1454 (D.C. Cir. 1992).5 The reasonableness "depends in large measure on what [the] determination [is] and the stated reasons behind it." Marcin v. Reliance Standard Life Ins. Co. , 138 F. Supp. 3d 14, 23 (D.D.C. 2015), aff'd , 861 F.3d 254 (D.C. Cir. 2017) (citation omitted); see also Black & Decker Disability Plan v. Nord , 538 U.S. 822, 825, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003) (). A plan administrator's decision was reasonable if it was "the result of a deliberate, principled, reasonable process and if it is supported by...
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