Halo v. Yale Health Plan
| Decision Date | 30 September 2014 |
| Docket Number | Civil Action No. 3:10–cv–1949 VLB. |
| Citation | 49 F.Supp.3d 240 |
| Court | U.S. District Court — District of Connecticut |
| Parties | Tiffany L. HALO, Plaintiff, v. YALE HEALTH PLAN, Defendant. |
Tiffany L. Halo, Denville, NJ, pro se.
Anthony D. Sutton, Patrick M. Noonan, Donahue, Durham & Noonan, Guilford, CT, for Defendant.
The Plaintiff, Tiffany L. Halo (“Halo”), who at all times relevant to this proceeding was a student at Yale University and an insured under Yale Health Plan (“YHP”), brings this action pro se against the Defendant, YHP, under the Employee Retirement Income Security Act of 1974 (“ERISA”). Plaintiff alleges that Defendant violated the provisions of 29 C.F.R. § 2560.503–1, which governs the timing of notification of benefit determinations, and that YHP acted in an arbitrary and capricious manner in denying her coverage for out-of-network urgent or emergency care.1 On August 19, 2011, YHP moved for judgment on the administrative record. See [Dkt. # 14]. Halo submitted a twenty-eight page objection to YHP's motion, citing Federal Rule of Civil Procedure 56 and applicable case law, see [Dkt. # 20, Pl.'s Resp. in Opp'n, at 1–2, 17–19], but did not file affidavits or other admissible evidence supporting her benefit claim. This Court treated YHP's motion as one for summary judgment and, relying on the administrative record upon which YHP based its decision, granted judgment on the administrative record in YHP's favor, on March 9, 2012. [Dkt. # 28].
On April 9, 2012, Halo appealed this Court's judgment. [Dkt. # 29]. On October 11, 2013, the Second Circuit vacated and remanded the judgment. [Dkt. # 34]. In its Summary Order, the Second Circuit held that Halo did not receive proper notice of the consequences of failing to respond to a motion for summary judgment. See [Dkt. # 34, Mandate of USCA, at 5]. Further, in response to the amicus curiae brief filed by the Department of Labor in support of Halo's appeal, in addition to the merits of Halo's claims, the Second Circuit directed this Court to consider whether YHP violated the procedural requirements for claim administration under 29 C.F.R. § 2560.503–1, and if so, whether Halo is entitled to civil penalties and to de novo review of her claims. [Id. at 6–7].
On December 27, 2013, YHP renewed its motion for judgment on the administrative record to affirm YHP's coverage decisions. [Dkt. # 38]. On February 24, 2014, Halo filed her Opposition to YHP's motion. [Dkt. # 43]. On March 21, 2014, YHP filed its Reply to Halo's Opposition. [Dkt. # 46]. On April 24 and September 2, 2014, Halo filed supplemental evidence and briefing. [Dkt. 20, 52 and 53]. After consideration of the record and the mandate of the Second Circuit, for the reasons stated hereinafter, the Defendant's motion for judgment on the administrative record is granted, in part, and denied in part.
As an enrolled student attending Yale at least half time and working towards a Yale degree, Halo was a member of the Yale Health Plan and received “YHP Basic” coverage at no charge. [Dkt. # 38–3, Ex. A (Yale Health Plan Student Handbook) at 11]. YHP Basic coverage included: Primary care through Yale's Student Medicine or Internal Medicine Departments, gynecology services, preventative medicine services, such as routine eye exams, flu shots, and skin cancer screening, laboratory services, access to 24–hour urgent care through the Urgent Care Department, mental health services, nutritional counseling, and some use of Yale's Inpatient Care Facility. [Id. ].
In addition to the YHP Basic plan, Halo purchased YHP Hospitalization/Specialty Coverage (the “Specialty Plan”). [Dkt. # 43, Opp. at 12]. The Specialty Plan offers three types of coverage “at 100%”: (i) outpatient specialty care received through the YHP health care network, (ii) approved inpatient care at YHP-approved inpatient facilities, and (iii) limited out-of-network care. [Dkt. # 38–3, Ex. A at 58].
Under the Specialty Plan, “[e]mergency care and pre-authorized follow-up care for emergency conditions is covered at 100% regardless of location.” [Id. at 62]. YHP defines an “emergency condition” as “a major acute medical problem or major acute trauma that requires immediate medical attention or a condition that could lead to serious harm or death if care is no received or is delayed.” [Id. ]. Emergency coverage includes “emergency facility fees, laboratory expenses, radiological expenses, emergency physicians' fees, ambulance transportation, and pre-authorized short-term follow-up care.” [Id. ].
In the event of an emergency condition, YHP instructs covered beneficiaries to “contact the YHP Care Coordination Department within 48 hours (or 2 business days) of receiving emergency outpatient treatment or being admitted to an emergency facility.” [Id. ]. After receiving notification of emergency care, the Care Coordination Department “will (1) notify YHP clinical staff of [the beneficiary's] condition so that they can coordinate [the beneficiary's] care as appropriate ... and (2) pre-authorize any necessary follow-up care.” [Id. ]. The Specialty Plan expressly warns that any “[f]ollow-up care that is not pre-authorized may be denied.” [Id. ].
The Specialty Plan also provides 100% coverage for “[u]rgent care at any medical facility” when a beneficiary is “away from New Haven County.” [Id. at 63]. YHP defines an “urgent condition” as “the sudden and unexpected onset of an acute medical problem or trauma that requires immediate medical attention.” [Id. ]. “Urgent conditions” do not include “chronic conditions, maintenance care, and routine care.” [Id. ]. As is the case with emergency care, beneficiaries are instructed to “contact the YHP Care Coordination Department within 48 hours (or 2 business days) of any care received out of area for an urgent condition to ensure that YHP clinical staff are aware of your condition and to request the Care Coordination Department to pre-authorize follow-up care.” [Id. ]. YHP also warns that “[f]ollow-up care that is not pre-authorized may be denied.” [Id. ].
Finally, YHP informs its beneficiaries that, [Id. ].
YHP's Student Handbook describes the procedures governing the submission of claims for coverage:
YHP also advises that “[c]laims for covered services are honored for one year from the date of service.” [Id. ]. In the event a claim is denied, beneficiaries “have a right to appeal the decision.” [Id. at 41]. YHP provides for a two-level appeals process. The first level “requires a request for reconsideration in writing within 180 days from the date of receipt of the initial determination.” [Id. ]. Once a beneficiary has received written notice that their first appeal was unsuccessful, they may request a second level appeal. “Second level appeals must be requested in writing within 60 days of receipt of the first level claim appeal determination and mailed to the Yale Health Plan Patient Representative.” [Id. ]. This second review “will be completed within 30 days of receipt of the [second] appeal.” [Id. ].
The series of incidents involving Plaintiff's eye condition began on May 31, 2008, when Halo developed a visual disturbance in her left eye. She went to the Yale University Health Services Urgent Care Department and was referred to Yale New Haven Hospital for an inpatient consultation. [Dkt. # 38–4, Ex. B, at 1–2]. She was examined by Dr. Joan Cho, who identified a “[f]ocal visual field abnormality” and recommended that the Plaintiff “be evaluated by ophthalmology today.” [Id. at 2]. Later that day, Halo went to Yale–New Haven hospital, an in-network care provider, for an eye consultation. [Dkt. # 43, Opp. at 9]. Halo was examined by Dr. Huffman. During his examination of Plaintiff's retina, Dr. Huffman detected “retinal folds” and a possible “small hole.” [Dkt. # 38–4, Ex. B, at 3].
At Dr. Huffman's direction, Halo returned to the hospital the following morning, June 1, 2008, for a new patient evaluation. [Dkt. # 43, Opp. at 9]. There, Dr. Kempton examined Plaintiff's eyes and determined that Halo had a “[r]etinal hole.” [Dkt. # 38–4, Ex. B, at 6]. Accordingly, Dr. Kempton recommended that Halo undergo a scleral buckle /cryotherapy procedure that day, June 1, with Dr. Liggett. [Id. ] Dr. Kempton also concluded that Halo “will need laser [r]etinopexy2 ... this week.” [Id. ] Plaintiff alleges in her Opposition that Dr. Kempton stated that “a retinal break is an eye emergency requiring immediate medical attention to prevent vision loss.” [Dkt. # 43, Opp. at 9–10]. The medical records prepared at the time of Halo's visit on June 1, 2008 do not describe her condition as “an eye emergency,” nor do they state that her condition “requir[es] immediate medical attention to prevent vision loss.” [Dkt. # 38–4, Ex. B, at 4–6].
On June 1, 2008, Dr. Kempton performed surgery on Halo's left eye. [Dkt. # 38–4, Ex. B, at 7–9]. The surgery was supervised by Dr. Peter Liggett, a...
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