Dragu v. Motion Picture Indus. Health Plan for Active Participants

• Decision Date: 16 November 2015
• Docket Number: Case No. 14–cv–04268–RS
• Citation: 144 F.Supp.3d 1097
• Court: U.S. District Court — Northern District of California
• Parties: Elise Dragu, Plaintiff, v. Motion Picture Industry Health Plan for Active Participants, Defendant.

144 F.Supp.3d 1097

Elise Dragu, Plaintiff,

v.Motion Picture Industry Health Plan for Active Participants, Defendant.

Case No. 14–cv–04268–RS

United States District Court, N.D. California.

Signed November 16, 2015

James Pieper Keenley, Emily A. Bolt, Brian Henry Kim, Bolt Keenley Kim LLP, Berkeley, CA, for Plaintiff.

Kristina Marie Zinnen, Ezekiel D. Carder, William A. Sokol, Weinberg Roger & Rosenfeld A Professional Corporation, Alameda, CA, for Defendant.

ORDER GRANTING PLAINTIFF'S AND DENYING DEFENDANT'S MOTIONS FOR SUMMARY JUDGMENT

RICHARD SEEBORG

, District Judge

I. INTRODUCTION

Plaintiff Elise Dragu mangled her jaw, mouth, teeth, and gums when she tumbled down a rocky creek while hiking in Northern California. She sought medical treatment for her various injuries from oral surgeon, Dr. Robert A. Shuken, D.D.S., who recommended extracting the damaged teeth, inserting bone grafts

where possible, implanting fixtures for implantation of abutments and crowns, and—lastly—installing abutments and crowns as replacements for the missing teeth. Dragu requested coverage for the medical procedures from her medical benefit plan, Defendant Motion Picture Industry Health Plan for Active Participants (“the Plan”), which is subject to the requirements of the Employee Retirement Income and Security Act (“ERISA”), 29 U.S.C.§ 1001 et seq.

The Plan initially denied coverage for dental implants

, including the implantation of fixtures and placement of abutments and crowns, on the basis that “Dental services are not covered under the Plan.” Keenley Decl. Ex. 4 at 532.¹ Dragu appealed the adverse determination to the Plan's Benefits/Appeals Committee. After reviewing the appeal, the Benefits/Appeals Committee paid Dr. Shuken for the installation of fixtures at a reimbursement rate of 50%, which was the rate available to out-of-network providers under the terms of the 2013 plan. With respect to Dragu's request for medical coverage for the placement of crowns and abutments, the Plan offered a different reason to deny the claim: “Dental implants

may be covered in cases of trauma, ablative surgery or congenital anomalies. Prosthetic rehabilitation of dental implants including abutments and crowns are not covered under the medical benefit.” Keenley Decl. Ex. 7 at 460. In her motion for summary judgment, Dragu contends that the Plan wrongfully denied coverage for the crowns and abutments and reimbursed Dr. Shuken at a lower rate than was required by the applicable plan. The Plan argues that its interpretation of the medical coverage agreement was proper and that it is entitled to attorney fees.

The Plan misinterpreted the plain language of the medical benefit plan when it denied Dragu coverage for the initial placement of abutments and crowns and reimbursed Dr. Shuken at the lower rate as required by the plain language of the medical benefit agreement. That interpretation of the terms of the plan was an abuse of discretion. Accordingly, Dragu's motion for summary judgment is granted; the Plan's is denied as is the Plan's request for attorney's fees.

II. FACTS AND PROCEDURAL HISTORY

While hiking in forests of the north coast of California, Dragu suffered terrible injuries to her wrists

, body, face, and mouth after falling into a steep river embankment. As a result of the fall, Dragu's jaw and teeth were fractured, and some of her teeth were torn from the roots or pushed out of position. After undergoing jaw surgery, Dragu sought treatment for her mouth and teeth from Dr. Shuken, who recommended that she undergo multiple surgeries, including the implantation of fixtures, and affixation of prosthetic teeth—abutments and crowns. To cover the expenses of the extensive mouth and jaw procedures, Dragu submitted claims for benefits to the Plan of which she is a beneficiary. The Plan is a self-funded group health plan which exists for the purpose of providing health and welfare benefits to eligible participants and their spouses and dependents.

A. Dragu's Treatment with Dr. Shuken: Teeth Removal and Installation of Fixures

In December 2012, after Dragu had been able to heal and recover, Dr. Shuken determined that six of her teeth needed to be removed. Before proceeding with the surgery, Dr. Shuken submitted a pre-approval authorization request, seeking authorization for approval to remove Dragu's unsalvageable teeth surgically, insert bone grafts

, and administer anesthesia. Included with the pre-authorization documents was the long-term treatment plan, which envisioned work with a prosthodontist to insert implants to replace the teeth. On February1, 2013, before the Plan responded to the pre-authorization request, Dragu underwent the tooth extraction surgery; Dr. Shuken placed bone grafts into her jaw where needed. Soon thereafter, the Plan approved Dr. Shuken's pre-approval request for surgical removal of teeth, bone replacement grafts, and anesthesia.

Happily, Dragu healed and went forward with the next phase of her treatment plan: the installation of fixtures. Again, on August 29, 2013, Dr. Shuken submitted a pre-approval authorization request for endosteal surgical implants—insertion of posts to anchor the crowns and abutments. Two weeks later, Dr. Shuken installed three fixtures successfully. On September 16, 2013, he submitted a claim for payment for the successful procedure.

B. The Plan Changes the Terms of the Summary Plan Descriptions (“SPDs”)

In the meantime, the Plan adopted and implemented a new SPD to go into effect on October 1, 2013, which superseded the 2007 SPD. The 2013 SPD became “effective for expenses incurred on or after October 1, 2013....” Keenley Decl. Ex. 10 at 157. Of particular importance was the change in coverage for “dental implants

.” Both the 2007 and 2013 SPDs did not provide coverage for “dental treatments” as a medical benefit with the exception of certain dental treatments for the following medical diagnoses: “myalgia, myositis, migraine, trigeminal neuralgia, sleep apnea, and temporomandibular joint disorder.” Compare Keenley Decl. Ex. 11 at 372 (2007 SPD), with id. Ex. 10 at 216 (2013 SPD). The 2007 SPD excluded dental implants from the services covered under the medical plan “except where there is no other dental alternative.” Keenley Decl. Ex. 11 at 380. In contrast, the 2013 SPD provided coverage for dental implants “in cases of trauma, ablative surgery or congenital anomalies. Prosthetic rehabilitation of dental implants including abutments and crowns are not covered under the medical benefit.” Id. Ex. 10 at 217.

C. Dragu's Treatment with Dr. Parvizpour: Placement of Abutments and Crowns

In fall 2013, following the successful fixture implantation, Dragu began her treatment with the prosthodontist, Dr. Shahariar Parvizpour, who submitted a pre-authorization request on October 31, 2013, for the placement of abutments and crowns into the fixtures. Dragu wanted to begin that procedure in November 2013, but she delayed the procedure to await the Plan's response to Dr. Parvizpour's pre-authorization request. Eventually, Dragu decided to pay for the procedure out of pocket and seek reimbursement. She underwent several procedures to install abutments and crowns in March, April, and June 2014.

D. Dragu's Administrative Appeal of the Adverse Benefits Determinations

On November 12, 2013, the Plan denied Dr. Shuken's pre-authorization request for the fixture implantation because “[d]ental services are not covered under the Plan.” Keenley Decl. Ex. 4. Dissatisfied with this response, on January 17, 2014, Dragu filed an appeal with the Benefits/Appeals Committee of the denial for fixture implantation seeking coverage for “all medically necessary procedures” for reconstruction

of her mouth. She specifically referenced the 2013 SPD's coverage of dental implants in cases of trauma and reconstructive surgery. Compare Keenley Decl. Ex. 6 at 472, with id. Ex. 10 at 217. C.H. Armstrong, the medical director of the plan, reviewed Dragu's appeal and concluded that the Plan should cover the implantation of the fixtures, but not the placement of abutments and crowns. Mason Decl. Ex. D–1 at 478, 493.² In February 2014, the Plan paid Dr. Shuken for the implants at a rate of 50% of the amount charged because he is an out-of-network provider. The Plan issued Dragu an explanation of benefits, which listed the payments for the installation of the fixtures, but did not reference the appeal.

Soon thereafter, Dr. Armstrong turned to review Dragu's appeal again. He prepared a memorandum for the Benefits/Appeals Committee, summarizing the appeal in which he again referenced the 2013 SPD's exclusion of “prosthetic rehabilitation of dental implants

” and noted that the Plan's “maxillofacial and oral surgeon consultant” reviewed the file and agreed that the placement of crowns and abutments did not qualify as a “medical benefit,” and is subject to the terms of the dental benefit plan. Keenley Decl. Ex. 8 at 461. On March 25, 2014, the Plan issued the following final decision regarding Dragu's “[r]equest for benefits for dental services—crowns and abutments”: “Your appeal was denied. The determination of the Committee was that per the Active MPI Health Plan Summary Plan Description, October 2013—page 57, ‘Prosthetic rehabilitation of dental implants including abutments and crowns are not covered under the medical benefit.’ ” Keenley Decl. Ex. 7 at 460.

Once again discouraged by the outcome of the administrative appeal, Dragu filed this claim for benefits pursuant to ERISA § 502(a)(1)(B). After exchanging discovery, Dragu and the Plan filed dueling motions for summary judgment. Dragu insists that the Plan made two erroneous determinations about her entitlement to benefits. First, she maintains that the Plan should have paid for the placement of crowns and abutments. Second, she contests the rate at which the Plan paid Dr. Shuken for the installation of fixtures into her mouth. The Plan paid Dr. Shuken at a rate of 50% of the allowable charge under the 2013...