Harvey T. v. Aetna Life Ins. Co.

• Decision Date: 15 December 2020
• Docket Number: Case No. 2:18-cv-00351-DBB-DAO
• Citation: 508 F.Supp.3d 1088
• Parties: HARVEY T., Jane R., and William T., Plaintiffs, v. AETNA LIFE INSURANCE COMPANY and the Invesco Life Cycle Flex Plan, Defendants.
• Court: U.S. District Court — District of Utah

508 F.Supp.3d 1088

HARVEY T., Jane R., and William T., Plaintiffs,

v.AETNA LIFE INSURANCE COMPANY and the Invesco Life Cycle Flex Plan, Defendants.

Case No. 2:18-cv-00351-DBB-DAO

United States District Court, D. Utah.

Signed December 15, 2020

Brian S. King, Nediha Hadzikadunic, Brian S. King PC, Salt Lake City, UT, for Plaintiffs.

David N. Kelley, Madelyn L. Blanchard, Scott M. Petersen, Fabian Vancott, Salt Lake City, UT, for Defendants.

MEMORANDUM DECISION AND ORDER DENYING [39] DEFENDANTS’ MOTION FOR SUMMARY JUDGMENT AND GRANTING IN PART AND DENYING IN PART PLAINTIFFS’ [40] MOTION FOR SUMMARY JUDGMENT

David Barlow, United States District Judge

Defendant Aetna Life Insurance Company (Aetna) denied Plaintiffs’ claims for healthcare reimbursement under an employee welfare benefits plan. Plaintiffs contend their claims were wrongly denied under the Employee Retirement Income Security Act of 1974 (ERISA).¹ Before the court are the parties’ cross-motions for summary judgment.² Having considered the briefing and the relevant law, the court denies Defendants’ Motion for Summary Judgment and grants in part and denies in part Plaintiffs’ Motion for Summary Judgment.

BACKGROUND

Harvey T. was a participant in the Invesco LifeCycle Flex Plan (Plan), an employee welfare benefits plan governed by ERISA.³ His son, W.T., was a beneficiary of the Plan.⁴ Aetna "provide[s] certain administrative services to the Plan."⁵ The Plan gives Aetna the "exclusive discretionary authority to construe and to interpret the plan, to decide all questions of eligibility for benefits, and to determine the amount of such benefits."⁶

The Plan covers certain medically necessary services, including mental health care.⁷ With respect to the type of mental health care covered, the Plan provides in relevant part,

Covered expenses include charges made for the treatment of mental disorders by behavioral health providers.

...

Not all types of services are covered. For example, educational services and certain types of therapies are not covered. See the Health Plan Exclusions and Limits section for more information.

Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility or behavioral health provider's office for the treatment of mental disorders as follows:

Inpatient Treatment

Covered expenses include charges for room and board at the semi-private room rate, and other services and supplies provided during your stay in a hospital, psychiatric hospital, or residential treatment facility. Inpatient benefits are payable only if your condition requires services that are only available in an inpatient setting.

Important Reminder

Inpatient care, partial hospitalizations and certain outpatient treatment must be precertified by Aetna. Refer to How the Plan Works for more information about precertification.⁸

The Plan defines "behavioral health provider/practitioner" as a "licensed organization or professional providing diagnostic, therapeutic or psychological services for behavioral health conditions."⁹ The Plan defines mental disorder as an

illness classified by Aetna as a mental disorder, whether or not it has a physiological basis, and for which treatment is generally provided by or under the direction of a behavioral health provider .... A mental disorder includes; but is not limited to:

• Alcoholism and substance abuse.

• Bipolar disorder

.

• Major depressive disorder.

• Obsessive compulsive disorder.

• Panic disorder.

• Psychotic depression.

• Schizophrenia.¹⁰

However, "[n]ot all types of services are covered. For example, educational services and certain types of therapies are not covered."¹¹ Under "Medical Plan Exclusions" the Plan indicates that it "covers only those services and supplies that are medically necessary and included in the What the Plan Covers section."¹² The "Medical Plan Exclusions" also list as excluded certain "Educational services:"

• Any services or supplies related to education, training or retraining services or testing, including: special education, remedial education, job training and job hardening programs;

• Evaluation or treatment of learning disabilities, minimal brain dysfunction

, developmental, learning and communication disorders, behavioral disorders, (including pervasive developmental disorders ) training or cognitive rehabilitation, regardless of the underlying cause; and

• Services, treatment, and educational testing and training related to behavioral (conduct) problems, learning disabilities and delays in developing skills, except as specifically covered under the Speech Therapy Rehabilitation Benefit in the What the medical Plan covers section.¹³

The Plan requires certain services to be precertified, which helps the beneficiary and the beneficiary's physician "determine whether the services being recommended are covered expenses under the plan" and "allows Aetna to help [the] provider coordinate [the] transition from an inpatient setting to an outpatient setting (called discharge planning), and to register [the beneficiary] for specialized programs or case management when appropriate."¹⁴ "Stays in a treatment facility for treatment of mental disorders or substance abuse treatment" require precertification.¹⁵ In instances when precertification was "not requested, but would have been covered if requested" then expenses are "covered after a precertification benefit reduction is applied."¹⁶ The benefit reduction is in the amount of $350.¹⁷

W.T. attended Daniels Academy, a licensed residential treatment center in Utah,¹⁸ from April 30, 2015 until August 11, 2016.¹⁹ W.T.’s parents did not precertify the services he received at Daniels Academy,²⁰ but later submitted the claims to Aetna.²¹ On February 19, 2016, Aetna denied the claims, providing that "[t]he plan has a specific exclusion for the requested service or treatment. Please see the exclusions listed in the Exclusions section of the benefit plan document."²² On April 4, 2016, Aetna sent W.T. a letter again explaining that the claims were denied based on "a specific exclusion for the requested service or treatment" and directing Plaintiffs to "the exclusions listed in the Exclusions section of the benefit plan document."²³

Plaintiffs submitted a Level One appeal.²⁴ Aetna upheld the denial of coverage citing a plan exclusion and referring Plaintiffs to Exclusions and Limitations section of their Certificate of Coverage.²⁵ Aetna also noted that Plaintiffs "did not meet [their] plan's precertification timeframe for [W.T.’s] stay" and so their "benefits were paid at a reduced rate."²⁶ Aetna listed the items it reviewed in making its determination.²⁷ It then included an excerpt from the "Treatment of Mental Disorders" part of the Plan, which states in relevant part,

Covered expenses include charges made for the treatment of mental disorders by behavioral health providers.

...

Not all types of services are covered. For example, educational services and certain types of therapies are not covered. See the Health Plan Exclusions and Limits section for more information.

Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility or behavioral health provider's office for the treatment of mental disorders as follows:

Inpatient Treatment

Covered expenses include charges for room and board at the semi-private room rate, and other services and supplies provided during your stay in a hospital, psychiatric hospital, or residential treatment facility. Inpatient benefits are payable only if your condition requires services that are only available in an inpatient setting.

Important Reminder

Inpatient care, partial hospitalizations and certain outpatient treatment must be precertified by Aetna. Refer to How the Plan Works for more information about precertification.²⁸

Plaintiffs then submitted a Level Two appeal.²⁹ Aetna again identified the materials it reviewed in making its determination,³⁰ and it upheld its denial of coverage.³¹ Aetna stated,

As explained in the [Plan], under the topic "Medical Plan Exclusions", it states: "Not every medical service or supply is covered by the plan, even if prescribed, recommended, or approved by your physician or dentist. The plan covers only those services and supplies that are medically necessary and included in the What the Plan Covers section. Charges made for the following are not covered except to the extent listed under the What the Plan Covers section or by amendment attached to this Booklet ... Unauthorized services, including any service obtained by or on behalf of a covered person without Precertification by Aetna when required. This exclusion does not apply in a Medical Emergency or in an Urgent Care situation."³²

"Because the claims were administratively denied as not covered, no medical necessity review was conducted."³³

LEGAL STANDARD

A. Summary Judgment Standard

"The court shall grant summary judgment 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."³⁴ "When both parties move for summary judgment in an ERISA case, thereby stipulating that a trial is unnecessary, ‘summary judgment is merely a vehicle for deciding the case; the factual determination of eligibility of benefits is decided solely on the administrative record, and the non-moving party is not entitled to the usual inferences in its favor.’ "³⁵

B. Review of Benefits Decision under ERISA

The court must first determine the standard under which to review Aetna's decisions. The United States Supreme Court has observed that "the validity of a claim to benefits under an ERISA plan is likely to turn on the interpretation of terms in the plan at issue."³⁶ Applying the law of trusts, the Court held that "a denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to...