Doe v. Intermountain Healthcare, Inc.
| Docket Number | 2:18-cv-807-RJS-JCB |
| Decision Date | 21 August 2023 |
| Parties | JANE DOE, by LINDA SMITH, as her personal representative, Plaintiff, v. INTERMOUNTAIN HEALTHCARE, INC. and SELECTHEALTH, INC., Defendants. |
| Court | U.S. District Court — District of Utah |
MEMORANDUM DECISION AND ORDER DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT ON COUNTS ONE THROUGH FOUR
ROBERT J. SHELBY United States Chief District Judge.
Plaintiff Linda Smith, as personal representative of Jane Doe,[1]brings this action under the Employee Retirement Income Security Act of 1974 (ERISA).[2] Plaintiff filed both individual and class action claims alleging Defendants Intermountain Healthcare, Inc. (IHC) and SelectHealth, Inc. violated ERISA and the Mental Health Parity and Addiction Equity Act (Parity Act) in denying residential mental health benefits to Doe.[3]Before the court is Plaintiff's Motion for Summary Judgment on Counts One Through Four (the individual claims).[4] For the reasons stated below, the Motion is DENIED.
Through her employer, Doe was a participant in an ERISA benefits plan (the Plan) from at least December 30, 2016 to July 31 2018.[5]IHC sponsored the Plan and SelectHealth acted as the claims review fiduciary.[6] Before turning to the legal issues, the court reviews the relevant Plan language Doe's medical and treatment history, and the procedural history of this case.
The Plan covers treatment for both medical/surgical care and mental health services.[7] To qualify for benefits, services must be “medically necessary.”[8]Under the Plan, “Medical Necessity is determined by SelectHealth's Medical Director or another Physician designated by SelectHealth.”[9] SelectHealth has “sole discretionary authority” to interpret Plan terms such as medical necessity and determine the availability of benefits under the Plan.[10] SelectHealth has developed additional medical policies “to serve as guidelines for coverage decisions.”[11]These policies detail when certain services are considered medically necessary and are “subject to change without notice.”[12]
Two SelectHealth internal policies are relevant here-Policy 475 and Policy 582. Policy 475 lists criteria for coverage at psychiatric residential treatment centers, including a requirement that treatment be “provided in reasonable proximity to a members[sic] community or residence and support system.”[13]Concerning this criterion, Policy 475 cites to the Substance Abuse and Mental Health Services Administration guidelines which indicate “outcomes are improved when residential care is provided in close proximity to the patient's home” because the treatment can incorporate a patient's community and family “to build a life that supports recovery.”[14] Policy 582 outlines different levels of care for behavioral health issues and incorporates InterQual criteria to evaluate whether certain care is medically necessary.[15]To qualify for admission to a residential mental health facility under InterQual, a patient must suffer severe mental illness that cannot be managed at a less intensive level of care or within their current living situation.[16]InterQual further requires a patient be reevaluated within the first few weeks to see if either a lower level of care is feasible, progress is being made at the current level of care, or more intensive care is needed.[17]
The Plan requires preauthorization to obtain benefits coverage for residential mental health services.[18]Greater coverage is provided for services received at in-network facilities than those at out-of-network facilities, but the Plan covers both.[19] Should a claim for benefits be denied, the Plan offers participants an internal review process consisting of one mandatory review and a possible voluntary review.[20] Participants obtain review of an adverse benefit determination by submitting to SelectHealth a written appeal along with any relevant documents, records, and other information.[21]“During the appeal process, no deference will be afforded to the adverse benefit determination, and decisions will be made by fiduciaries who did not make the adverse benefit determination.”[22]A participant must exhaust the mandatory review before pursuing civil action under ERISA.[23]
In 2016, Doe sought mental health treatment for depression after struggles with her work as a physician.[24] Doe presented as “very suicidal” and was diagnosed with Major Depressive Disorder (MDD), Post Traumatic Stress Disorder (PTSD), and Insomnia Disorder.[25]She received prescriptions to treat her symptoms but was unwilling to do therapy and would not limit her access to guns.[26] Although Doe's doctor discussed voluntary and involuntary hospitalization with her, he ultimately determined she did not meet the criteria for admission.[27]
The medications only slightly alleviated Doe's symptoms and by late 2016 she was hospitalized three separate times for attempted suicide.[28]Hospital doctors determined Doe was a good candidate for electroconvulsive therapy (ECT) and she began receiving treatments on an outpatient basis.[29] Doe “noted significant improvement with regular ECT treatments,” reporting no suicidal ideation and reduced depressive symptoms.[30] As Doe tapered the frequency of her ECT treatments however, she began to experience worsening depressive symptoms and suicidal ideation.[31]Doe eventually checked into an out-of-state psychiatric hospital where she remained until April 2017.[32] SelectHealth covered a portion of Doe's stay at the psychiatric hospital but denied the final few weeks after determining Doe had “no ongoing safety issues” and her symptoms could be “handled safely in outpatient” care.[33]While hospitalized, Doe was terminated from her job.[34]
A. First Stay at Austen Riggs
On April 10, 2017, Doe checked into Austen Riggs Center, a residential mental health treatment facility in Massachusetts (First Stay).[35]On admission, Doe stated she did “not believe she [could] return to Utah” as “she would need to live with her parents, have no job, [and] she would be moved to take action on ending her life.”[36] Staff considered Doe a “significant risk to seriously harm” herself and found her condition had “been unresponsive to an appropriate course of treatment at a less intensive level of care.”[37] Doe was diagnosed with MDD, PTSD, and schizoid personality disorder.[38]It was anticipated Doe would stay for six weeks with longer treatment possible.[39] She was admitted on a short-term basis leading to stepdown care.[40] A goal sheet completed at admission listed short-term and long-term goals, such as gaining sufficient self-management skills to discharge to outpatient treatment.[41] Doe remained at Austen Riggs for four months.[42]During this stay, suicidal ideation was a constant concern, although Doe's depressive symptoms would “wax and wane.”[43]Additionally, on several occasions doctors noted concerns about Doe's poor nutrition, weight loss, and over-exercise.[44] Doctors twice ascribed to Doe an “unspecified Feeding and Eating Disorder.”[45]After a month, Doe was sent for a physical to address these concerns.[46] A doctor conducted a full exam before concluding Doe was likely “over-reporting her mileage that she is running and under-reporting food intake because her electrolytes were all normal . . . and she has not lost any weight.”[47]
Therapy during this stay was mostly unsuccessful. Doe participated only minimally and refused to engage with peers and the therapeutic community, limiting her interactions to doctors and staff.[48]On a couple occasions Doe did talk about receiving community support from her mother and stepfather although she “intimated to [a] staff member that even [her stepfather] could not keep her from killing herself.”[49] Eventually, Doe's suicidality escalated and she was involuntarily committed for psychiatric hospitalization.[50] After a nine-day psychiatric hospitalization, Doe elected to return to Utah with her mother and stepfather.[51]
B. Second Stay at Austen Riggs
Doe spent nearly a month with her mother and stepfather before reentering Austen Riggs for additional treatment on September 13, 2017 (Second Stay).[52]In her consultation for the Second Stay, Doe said her time at home had “helped her feel less desperate and depressed”[53]and she “express[ed] interest in re-entering treatment as a way to claim a life she imagines worth having.”[54] She reported that “she had a good month with her parents, feeling their love and support, which left her not wanting to devastate them with her suicide.”[55]While home, her eating and exercising had normalized and she denied having any psychotic symptoms or current suicidal ideation.[56]A mental status exam found Doe was “mildly depressed although improved since leaving.”[57]
Nevertheless, Doe again met the criteria for admission.[58] Staff found inpatient care was warranted based in part on Doe's prior suicide attempts and that she had previously been unresponsive to treatment at a lower level.[59]Doe communicated an increased motivation and renewed commitment “to do things differently, not only in being forthcoming about her risk of suicide . . . but also around managing her weight, [food] intake and exercise.”[60] Her decision to return rested on the realization that “feeling better at home could not translate into . . . get[ing] better and return[ing] to her profession.”[61]Additionally, Doe continued to struggle with PTSD symptoms such as “nightmares, flashbacks, and disassociation.”[62] Doe was admitted for a two week re-evaluation period during which staff and Doe would assess whether treatment at Austen Riggs was viable.[63]
Doe's two-week evaluation period...
To continue reading
Request your trial