Pleasant v. Shield

• Decision Date: 16 May 2014
• Docket Number: No. 69143–1–I.,69143–1–I.
• Citation: 325 P.3d 237,181 Wash.App. 252
• Court: Washington Court of Appeals
• Parties: Bruce PLEASANT and Kimberly Pleasant, a marital community, Appellants, v. REGENCE BLUE SHIELD, Respondent.

181 Wash.App. 252

325 P.3d 237

Bruce PLEASANT and Kimberly Pleasant, a marital community, Appellants,

v.REGENCE BLUE SHIELD, Respondent.

No. 69143–1–I.

Court of Appeals of Washington,

Division 1.

March 31, 2014.

Publication ordered May 16, 2014.

Rick J. Wathen, Kimberly Larsen Rider, Cole/Wathen/Leid/Hall, P.C., Seattle, WA, for Appellants.

Stephania Camp Denton, Mills Meyers Swartling, Seattle, WA, for Respondent.

SCHINDLER, J.

¶ 1 Bruce Pleasant sued Regence BlueShield alleging breach of contract, bad faith, and violation of the Consumer Protection Act, chapter 19.86 RCW, for denying coverage for nonrehabilitative services and medications he received during inpatient rehabilitation and for a mechanical embolectomy procedure. On cross motions for summary judgment, the court dismissed the lawsuit against Regence. We affirm.

FACTS

¶ 2 Bruce Pleasant had an individual health care plan with Regence BlueShield in 2010. The health care plan was approved by the Washington State Office of the Insurance Commissioner.¹

¶ 3 On March 18, 2010, 50–year–old Pleasant suffered a stroke while undergoing knee surgery at Stevens Hospital. Pleasant was transported to Swedish Medical Center and admitted to the intensive care unit (ICU). The doctors performed a number of medical procedures including a mechanical embolectomy.²

¶ 4 On March 22, Pleasant's relative, Bob Quigley, called Regence to ask about rehabilitation coverage. Regence informed Quigley that the health care plan had a “$4,000 per calendar year maximum” for inpatient rehabilitation. The transcript of the phone call between Quigley and Regence customer service representative Shannon Grim states, in pertinent part:

BOB: He's going to need therapy, some sort of rehabilitation therapy. Is there a special coverage for that?

SHANNON: There is, and I want to be able to explain it so it isn't confusing. It is considered a rehab benefit, which is occupational, rehab, speech, massage therapy, all under the same benefit.... For inpatient, ... there is a $4,000 per calendar year maximum. That is for while he's in the hospital, that's the inpatient rehab.

¶ 5 On March 24, the family met with a care manager at Swedish Medical Center. The family told the care manager they were interested in the Acute Rehabilitation Unit (ARU) at Swedish where an inpatient receives “three hours of therapy a day, seven days a week.” The care manager reiterated that the health care plan had a $4,000 limit for inpatient rehabilitation and discussed other options. But the family told the care manager they were “only interested in ARU at this time” and “may be willing to pay privately for ARU.” The care manager suggested the family meet with ARU admission coordinator Meghan Trigg. The March 24 medical records state, in pertinent part:

I spoke with pts [ (patient's) ] wife ..., daughter ..., and Son ... in room about plan of care.... They would like pt. [ (patient) ] to go to ARU. I explained that pt. has a limited benefit [for rehabilitation].... I will have ARU Coordinator, Meghan Trigg discuss with them. I will also give them SNF [ (skilled nursing facility) ] options but they really are only interested in ARU at this time. Wife ... has discussed hiring PT/OT [ (physical therapist/occupational therapist) ] at home and ... family may be willing to pay privately for ARU.

¶ 6 When Trigg met with the family to discuss inpatient rehabilitation, she also reiterated the Regence health care plan had a $4,000 limit and gave the family a benefits form. The benefits form states for “stay on the inpatient rehabilitation unit are: Covered at 80%. Limit $4000 per 12 months.” Trigg discussed a number of other options with the family including using the benefit for a 30–day stay at a skilled nursing facility. ³ The March 24 medical records state, in pertinent part:

Unfortunate situation in that patient has limited ARU benefit of $4000. Discussed this with the whole family today.... I gave them several options:

1. They could have patient transfer to SNF and start therapy and work up to ARU in order to save some money. Patient could return to ARU when he is really able to maximize its benefit before returning home. This would allow him to return home with better function and be the least expensive.

2. They could come to ARU and focus efforts and therapy on discharge to home with hospital bed, bedside commode, and wheelchair, this would shorten the stay, and get the patient home as quickly as possible. The family would then need to provide 24 hour care or hire help.

3. They could come directly to ARU and stay until they are comfortable taking him home. This would be the most expensive option.

¶ 7 On March 25, one of the treating doctors, Dr. David Clawson, met with Pleasant and his family to discuss rehabilitation. Dr. Clawson recommended Pleasant use skilled nursing care and “reevaluate his progress in a month” before considering “bring[ing] him onto an acute rehabilitation service.” The medical records state, in pertinent part:

My understanding is that [Pleasant] has a limited rehabilitation benefit and I think in this early phase of his postacute care he would [be] best served in a subacute or skilled nursing setting. We can reevaluate his progress in a month, and then consider bring[ing] him onto an acute rehabilitation service with eventual hope of a community discharge.

¶ 8 Pleasant decided to use the skilled nursing benefit before using the limited rehabilitation benefit and “then pay privately at ARU when ARU benefit has been exhausted.” The medical records for March 30 state, in pertinent part:

Patient has 30 day SNF benefit under insurance policy whereay [sic] he has a $4000 ARU benefit (a little over 2 days). Per discussions with ARU Coordinator, Meghan Trigg, PT/OT, and Dr. Clawson, pt. should utilize SNF benefit first to strengthen [right] leg and then return to ARU (which has accepted him). Pt. will then pay privately at ARU when ARU benefit has been exhausted.

¶ 9 On April 5, Swedish discharged Pleasant to an inpatient skilled nursing facility, The Springs at Pacific Regent. Thirty days later, on May 5, the ARU admitted Pleasant as an inpatient for “rehabilitation.” The ARU provides intensive rehabilitation therapy only to patients who are medically stable.

¶ 10 The medical records for May 5 state the inpatient ARU admission for Pleasant is “Physician Referral (Non- health Care Facility Point of Origin),” and the “Reason for Admission” is “for rehabilitation.” The “ Admission Type” is “Elective,” the “Primary Service” is identified as “Rehab,” and the “Secondary Service” is listed as “None.” Pleasant left the ARU on May 31.

¶ 11 Regence paid approximately $250,000 for the inpatient hospital care Pleasant received at Swedish from March 18 until his discharge on April 5. Regence also paid for the one month of inpatient skilled nursing care at The Springs at Pacific Regent.

¶ 12 Under the terms of the health care plan, Regence paid only $4,000 for the rehabilitation expenses incurred while Pleasant was an inpatient at the ARU. Pleasant incurred approximately $138,000 in medical expenses while a rehabilitative inpatient at the ARU—approximately $95,000 for rehabilitation and physical, occupational, and speech therapy, $25,600 for medications, and the remaining $17,400 for medical and surgical supplies and devices and laboratory tests.

¶ 13 Regence did not pay $415 for the mechanical embolectomy procedure. On July 8, 2010, Regence sent Pleasant a letter concerning denial of coverage for the mechanical embolectomy. Regence explained that under the “Regence Medical Policy Mechanical Embolectomy for Treatment of Acute Stroke” (Medical Policy), the procedure was excluded as “investigational” and provided a link to the Medical Policy posted on its website. The Medical Policy states, in pertinent part:

Mechanical embolectomy is considered investigational in the treatment of acute stroke.

....

The available published data are not sufficient to determine whether this approach improves health outcomes.... Given the lack of controlled studies to assess the impact of this treatment on outcome, the effectiveness of mechanical embolectomy for the management of acute stroke remains uncertain.

¶ 14 On February 9, 2011, Pleasant filed a lawsuit against Regence alleging breach of contract, bad faith, and violation of the Washington Consumer Protection Act (CPA), chapter 19.86 RCW, for refusing to pay for services and drugs he received while an inpatient at the ARU.

¶ 15 Pleasant filed a motion for summary judgment arguing he was entitled to payment for the medically necessary services and medications he received while a rehabilitative inpatient at the ARU. Pleasant relied on the provision of his health care plan that states when confined as an inpatient at a hospital, “[b]enefits will be provided for services and supplies ... determined to be Medically Necessary.” Pleasant also submitted the declaration of Dr. Clawson. Dr. Clawson states that Pleasant received “medically necessary” care while at the ARU. The declaration states, in pertinent part:

Mr. Pleasant received treatment while at the rehabilitation center. He received certain treatment which was medically necessary regardless of the setting in which he received the treatment. Examples include medication, laboratory work, and a CT ⁴ scan. Additionally, Mr. Pleasant underwent a procedure to remove and replace a blood filter. Again, these are treatments Mr. Pleasant received related to his stroke. The procedures, lab work and medicines were needed regardless of Mr. Pleasant's setting. In other words, Mr. Pleasant would have needed these treatments whether or not he had been admitted for in-patient rehabilitative services.

¶ 16 Regence filed a cross motion for summary judgment. Regence argued there was no dispute Pleasant was admitted to the ARU as an inpatient for rehabilitation and the health care plan expressly limited coverage for inpatient...