Halberg v. United Behavioral Health

Decision Date30 September 2019
Docket Number16-CV-6622 (MKB) (SJB)
Citation408 F.Supp.3d 118
Parties Samuel Shmarya HALBERG and C.H., Plaintiffs, v. UNITED BEHAVIORAL HEALTH, d/b/a OptumHealth Behavioral Solutions, Defendant.
CourtU.S. District Court — Eastern District of New York
MEMORANDUM & ORDER

MARGO K. BRODIE, United States District Judge:

Plaintiffs Samuel Shmarya Halberg and C.H.1 commenced the above-captioned action on November 30, 2016, against Defendant United Behavioral Health ("UBH"), doing business as OptumHealth Behavioral Solutions. (Compl., Docket Entry No. 1.) Plaintiffs allege that Defendant improperly denied coverage for C.H.'s medical treatment, disregarding C.H.'s treatment records and misapplying Defendant's own "level of care criteria." (Id. ¶ 5.) Plaintiffs seek to recover unpaid benefits pursuant to sections 502(a)(1)(B), 502(a)(3), and 503(2) of the Employment Retirement Income Security Act of 1974, as amended, 29 U.S.C. § 1001 et seq. ("ERISA"). (Id. ¶¶ 24–35.) The parties cross-move for summary judgment. (Pls. Mot. for Summ. J. ("Pls. Mot."), Docket Entry No. 29; Pls. Mem. in Supp. of Pls. Mot. ("Pls. Mem."), Docket Entry No. 29-1; Def. Mot. for Summ. J. or Alternatively to Stay ("Def. Mot."), Docket Entry No. 38; Def. Mem. in Supp. of Def. Mot. ("Def. Mem."), Docket Entry No. 42-4.) Defendant also moves, in the alternative, to stay the action pending resolution of a related class action, Wit v. United Behavioral Health , No. 14-CV-2346, currently before the United States District Court for the Northern District of California. (Def. Mot.; Def. Mem. 17.) On April 9, 2019, the Court referred the motions to Magistrate Judge Sanket J. Bulsara for a report and recommendation. (Order dated April 9, 2019.)

By report and recommendation dated July 30, 2019 ("the R & R"), Judge Bulsara recommended that the Court grant Defendant's motion for summary judgment and deny Plaintiffs' motion for summary judgment. (R & R, Docket Entry No. 49.) Plaintiffs timely objected to the R & R, and Defendant replied to Plaintiffs' objections. (Pls. Obj. to R & R ("Pls. Obj."), Docket Entry No. 50; Def. Reply to Pls. Obj. ("Def. Reply to Obj."), Docket Entry No. 51.)

For the reasons set forth below, the Court adopts the R & R in its entirety and grants Defendant's motion for summary judgment and denies Plaintiffs' motion for summary judgment.

I. Background

The Court assumes familiarity with the underlying facts as detailed in the R & R and provides only a summary of the pertinent facts.

a. C.H.'s medical treatment and Defendant's coverage decisions

Plaintiffs were beneficiaries of a group health plan (the "Plan") sponsored by C.H.'s mother's employer, AXA Equitable Life Insurance Company ("AXA"). (Pls. Stmt. of Material Facts Pursuant to L. Rule 56.1 ("Pls. 56.1") ¶ 1, Docket Entry No. 29-2; Def. Stmt. of Material Facts Pursuant to L. Rule 56.1 ("Def. 56.1") ¶ 1, Docket Entry No. 42-3.) Defendant administered the benefits under the Plan. (Pls. 56.1 ¶ 1; Def. 56.1 ¶ 2.)

In September of 2011, following a suicide attempt, C.H. was hospitalized at Weill Cornell Medical Center ("Weill Cornell"), admitted to the pediatric intensive care unit, and subsequently transferred to adolescent inpatient psychiatric services. (Pls. 56.1 ¶ 5; Def. 56.1 ¶¶ 7–8.) On September 26, 2011, C.H. was discharged from Weill Cornell and admitted to the 2East residential treatment program (the "2East Program") at McLean Hospital ("McLean"), where she remained until December 27, 2011. (Pls. 56.1 ¶¶ 6, 9; Def. 56.1 ¶¶ 11–12.) Defendant approved coverage for C.H.'s treatment at Weill Cornell, as well as for C.H.'s treatment in the 2East Program. (Def. 56.1 ¶¶ 10, 13.)

On December 27, 2011, C.H. left the 2East Program and was admitted to the 3East residential treatment program (the "3East Program"), also at McLean. (Pls. 56.1 ¶¶ 8–9; Def. 56.1 ¶ 14.) While the parties agree that the 3East Program was residential, they disagree as to whether it "provide[d] 24-hour monitoring." (Def. 56.1 ¶ 19; Pls. Resp. to Def. 56.1 ("Pls. 56.1 Resp.") ¶ 19, Docket Entry No. 32-1.) C.H. remained in the 3East Program for nearly a year and a half, until May 8, 2013. (Pls. 56.1 ¶ 9; Def. 56.1 ¶ 17.) Plaintiffs contend that while enrolled in the 3East Program, C.H. "persistently threaten[ed] suicide and engage[d] in cutting and other self-harm." (Pls. 56.1 ¶ 10.) Defendant agrees that C.H. engaged in cutting on fifteen occasions and "continued to have suicidal ideation," but denies that C.H. was actively suicidal, based on medical staffs' failure to describe any of the "cutting incidents ... as suicide attempts or as life threatening" and medical notes describing "persistent intermittent suicidal thoughts." (Def. Resp. to Pls. 56.1 ("Def. 56.1 Resp.") ¶ 10, Docket Entry No. 42-6.) While C.H. was enrolled in the 3East Program, she was hospitalized on multiple occasions. (Def. 56.1 ¶¶ 34–36.) Defendant approved coverage for each of these hospitalizations. (Id. ¶ 47.)

Defendant approved coverage for C.H.'s treatment in the 2East Program from September 26, 2011 through December 27, 2011. (Pls. 56.1 ¶ 17; Def. 56.1 Resp. ¶ 17.) Defendant approved coverage for C.H.'s stay in the 3East Program from December 27, 2011 through January 14, 2012, but denied coverage for her treatment in the 3East Program from January 15, 2012 through May 8, 2013. (Def. 56.1 ¶ 55; Pls. 56.1 Resp. ¶ 55; Pls. 56.1 ¶ 17; Def. 56.1 Resp. ¶ 17.)

C.H., through Halberg and C.H.'s mother, sought timely administrative review of Defendant's decisions to deny coverage for C.H.'s treatment at the 3East Program from January 15, 2012 to May 8, 2013. (Def. 56.1 ¶ 49; Pls. 56.1 ¶ 22; Def. 56.1 Resp. ¶ 22.) After reviewing Plaintiffs' appeals, Defendant's physician reviewers affirmed the denials, concluding that coverage of C.H.'s treatment was not appropriate because "the services [C.H.] was receiving were not consistent with generally accepted standards of medical practice for the noted symptoms at this level of care and were considered inappropriate/inconsistent per UBH Cover Determination Guideline for Major Depressive and Dysthymic Disorder

at the residential level of care." (Def. 56.1 ¶ 51.) Defendant's physician reviewers further concluded that "treatment could have been provided at a lower level of care and therefore [the services C.H. was receiving] were non-covered health services." (Id. ¶ 52.) Although Plaintiffs agree that these were the physician reviewers' stated reasons for denying Plaintiffs' appeals, Plaintiffs dispute that "such findings were correct or accurately reflected [Defendant's] true rationale for denying coverage." (Pls. 56.1 Resp. ¶¶ 51–52.)

Plaintiffs sought external review of Defendant's denials by an Independent Review Organization ("IRO"). (Def. 56.1 ¶ 56.) On January 30, 2015, MCMC, an IRO, "reviewed C.H.'s request for coverage ... and upheld the decision to deny coverage from January 15, 2012 going forward because treatment ‘could have been safely and effectively provided at a lower level of care.’ " (Id. ¶¶ 58, 61 (quoting MCMC Decision Notification dated Jan. 30, 2015 ("MCMC Decision") Bates-stamped HAL 5795, annexed to Decl. of Denise C. Strait ("Strait Decl.") as Ex. A, Docket Entry No 42-1.) MCMC based its decision on its findings that, inter alia , C.H. was (1) "cooperative and effectively engaged in treatment," (2) "had no complicating general medical or clinical or psychiatric features that would necessitate [twenty-four]-hour monitoring or structure of residential level services," (3) "did not display active suicidal behaviors despite chronic suicidal ideation

that was amenable to treatment at a lower level of care with intensive services," and (4) "had ... social support ... [and] access to intensive treatment and services in the community." (MCMC Decision HAL 5797; see also Def. 56.1 ¶ 61; Pls. 56.1 Resp. ¶ 61.)

Defendant contends that MCMC "reviewed the health plan documents, including case notes and correspondence, [C.H.'s] appeal documents, case records ... case summary, and letters from ... C.H.'s father and providers," as well as "the Summary Plan Description, level of care guidelines pertaining to residential level services and treatment, and coverage determination guidelines pertaining to depressive disorder

." (Def. 56.1 ¶¶ 59–60.) Plaintiffs "[d]ispute[ ] that MCMC was provided with the relevant health plan documents." (Pls. 56.1 Resp. ¶¶ 59–60.)

b. Plan documents

The parties disagree as to which documents governed C.H.'s benefits under the Plan.2

In a sworn declaration dated May 16, 2018, Michael Francesconi, Senior Director of Benefits at AXA, states that "during the relevant time period" at issue in this case, C.H. was enrolled in a "group health plan" — constituting one "portion" of the welfare benefit program sponsored by AXA (the "AXA Welfare Plan" or "Plan"). (Decl. of Michael A. Francesconi dated May 16, 2018 ("2018 Francesconi Decl.") ¶¶ 1–2, annexed to Def. Mot., Docket Entry No. 38-3.) The "plan document" governing the AXA Welfare Plan consists of "multiple segments," one of which "includes general terms and procedures that govern each of the individual segments of the AXA Welfare Plan." (Id. ¶ 3.) In addition to this "[a]dministrative [p]ortion," the plan document includes "separate individual segments ... that describe the benefits applicable to each particular aspect of the [AXA Welfare] Plan." (Id. ) Francesconi further attests that the attached "portion of the AXA Welfare Plan document describe[es] the plan benefits for the group health plan in which ... C.H. was enrolled during the time [period] referenced ... in this matter." (Id. ¶ 5.) The document Francesconi describes is titled "Chapter 2: About [UBH] Medical Coverage Preferred Provider Organization (PPO) Options."

(AXA Welfare Plan Document ("UBH SPD"),3 annexed to 2018 Francesconi Decl. as Ex. B., Docket Entry No. 38-3.) Defendants contend that the UBH SPD governed C.H.'s benefits. (Def. 56.1 ¶ 3.)

The first paragraph of the UBH SPD...

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