Prowell v. UPS Flexible Benefits Plan
| Decision Date | 26 October 2011 |
| Docket Number | Civil Case No. L-10-3457 |
| Parties | ROBERT PROWELL Plaintiff v. UPS FLEXIBLE BENEFITS PLAN Defendant |
| Court | U.S. District Court — District of Maryland |
This is an ERISA case. Plaintiff, Robert Prowell, individually and as guardian of SP, appeals the decision of Defendant, UPS Flexible Benefits Plan, denying benefits under the terms of a health benefit plan in which he is a participant. Now pending before the Court are the parties' Cross-Motions for Summary Judgment. Docket Nos. 28 and 31. The issues have been comprehensively briefed, and on September 9, 2011, the Court convened a hearing and heard oral argument. For the reasons stated herein, the Court will, by separate Order, DENY the parties' Cross-Motions for Summary Judgment and REMAND Plaintiff's claim to the plan administrator for a full and fair review consistent with this Memorandum Opinion.
SP is a six-year-old girl who has been diagnosed with numerous medical problems, including "autism, pervasive developmental delay, gastroesophegeal reflux, and feeding disorder and mismanagement." Pl.'s Mot. Summ. J. 1, Docket No. 28. As a result of her condition, she has extreme difficulty consuming solid foods. SP underwent extensive evaluation at theKennedy Krieger Institute ("KKI"), a medical facility dedicated to the treatment of children and adolescents. The evaluation took place at KKI's Feeding and Swallowing Clinic, and involved review by experts in behavioral psychology, nutrition, speech and language therapy, and pediatric gastroenterology. Following this evaluation, doctors recommended SP's admission into KKI's Pediatric Feeding Disorders Program for a period of six to eight weeks.
Prowell, SP's father, is an employee of United Parcel Service ("UPS") and a qualified participant in the UPS Flexible Benefits Plan, Group Number 221775 (the "Plan"), pursuant to § 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132(a)(1)(B). The Plan provides coverage for, inter alia, "charges made by a physician or a licensed or certified physical or occupational therapist for furnishing short-term rehabilitation services for treatment of acute conditions . . . ." Administrative Record (hereinafter "AR") at 671. The terms of the Plan define rehabilitation as "physical therapy or occupational therapy for the improvement of a body function that has been lost or impaired due to injury or illness." Id. at 672.
United Healthcare Insurance Company ("United") is the Plan's third-party administrator; it is granted discretion under the Plan to perform certain administrative services, including preliminary determination of eligibility for benefits. On April 13, 2010, United denied Prowell's request for authorization on the ground that the requested services "are not eligible expenses under the patient's plan." Id. at 41. Specifically, United found that "[a] pediatric behavior modification program will treat food aversion which is not an illness or injury." Id.
Prowell appealed. On July 30, 2010, United upheld its earlier decision, but added a separate basis for the denial of benefits. In addition to the determination that there was no underlying disease or illness causing SP's condition, United stated that the proposed treatmentwas "unproven" and cited a section of the Plan description that reads, Id. at 155. The conclusion that the proposed treatment was experimental was based on the findings of Dr. Steven Lichtman, an independent pediatric gastroenterologist who reviewed SP's case. Dr. Lichtman was asked the following question:
If there is an underlying medical disease/illness/injury which has resulted in this child's food aversions and the need for an intensive feeding therapy program, is the clinical data from well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature adequate to conclude that an intensive day treatment feeding program such as the multidisciplinary program offered by [KKI] for this child which includes pediatric GI services, nutrition, nursing , social services, occupational therapy, speech therapy, and behavioral psychology, [is] effective for the treatment of food aversions due to the above identified medical disease/illness(es) or injury(ies)?
Id. at 106. In response to this question, Dr. Lichtman answered simply, "No."1 Id. In a later section of his report, captioned "Rationale," he elaborated:
Prowell appealed this decision as well. In support of his appeal, he submitted a letter from KKI responding to United's conclusions. See id. at 268-84; Compl. Ex. B, Docket No. 2-2. The letter recounts with some specificity KKI's success in treating children with severefeeding disorders, and asserts that KKI has treated "well over a thousand children" over a 20-year period. Id. at 3-4. The letter also cites fourteen articles, including a "comprehensive review . . . [of] over 74 studies that examined the effectiveness of various behavioral interventions in treating feeding disorders," which KKI characterizes as "a small sample of the peer-reviewed articles that have been published from the data generated our [sic] program." Id. at 1-3, 1. The letter asserts, "In short, there is no basis whatsoever for your agency's contention that these programs are experimental or lack sufficient support in the scientific literature." Id. at 3.
This second appeal was decided not by United, but by the UPS Claims Review Committee ("Review Committee"), which has authority under the Plan to issue final benefit determinations. In aid of its decision, the Review Committee requested the opinion of another independent pediatric gastroenterologist, Dr. Ding-You Li. Dr. Li determined that the previous reviews had been incorrect, and that there was in fact an underlying disease, illness, or injury that resulted in SP's food aversions. See AR at 250. Like Dr. Lichtman, however, Dr. Li also responded in the negative to the second question, quoted in full above, asking whether clinical data from well conducted randomized controlled or cohort trials established the effectiveness of the treatment. See id. at 251.
Dr. Li's written report cited seven studies that he retrieved and reviewed, and concluded that "[a]ll of the above literature demonstrated the effectiveness of intensive interdisciplinary feeding for children with food refusal and feeding difficulty." Id. at 252. Dr. Li continued, however: Id.
Based on Dr. Li's opinion, the Review Committee issued a final denial of benefits letter on October 15, 2010. See id. at 215-17. Following that denial, Prowell filed the instant suit on December 9, 2010. Both parties' Motions for Summary Judgment have been fully briefed, and the issues presented therein are ripe for decision.
ERISA actions are usually adjudicated on summary judgment rather than at trial. Carden v. Aetna Life Ins. Co., 559 F.3d 256, 260 (4th Cir. 2009). The Court may grant summary judgment when "the pleadings, depositions, answers to interrogatories, and admissions on file, together with affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(c); Celotex Corp. v. Catrett, 477 U.S. 317, 322-23 (1986); see also Felty v. Graves-Humphreys Co., 818 F.2d 1126, 1128 (4th Cir. 1987) (). Nevertheless, in determining whether there is a genuine issue of material fact, the Court views the facts, and all reasonable inferences to be drawn from them, in the light most favorable to the non-moving party. Pulliam Inv. Co. v. Cameo Properties, 810 F.2d 1282, 1286 (4th Cir. 1987).
"When both parties file motions for summary judgment . . . [a] court applies the same standard of review." McCready v. Standard Ins. Co., 417 F. Supp. 2d 684, 695 (D. Md. 2006) (citing Taft Broad. Co. v. United States, 929 F.2d 240, 248 (6th Cir.1991)). Furthermore, "each motion [will be considered by a court] separately on its own merits to determine whether eitherof the parties deserves judgment as a matter of law." Rossignol v. Voorhaar, 316 F.3d 516, 523 (4th Cir. 2003).
In reviewing a claim of wrongful denial of benefits under ERISA, the Court must first determine whether that plan vested the plan administrator with discretion to determine eligibility of the contested benefits. See Blackshear v. Reliance Standard Life Ins. Co., 509 F.3d 634, 638 (4th Cir. 2007). The Court makes this determination de novo. Id. If the Court determines that the plan confers discretionary authority on the administrator, then the court reviews the administrator's decision under an abuse of discretion standard. Evans v. Eaton Corp. Long Term Disability Plan, 514 F.3d 315 (4th Cir. 2008).
Under the abuse of discretion standard, the Court must determine whether the administrator's denial of benefits was reasonable. See Groft v. Health...
To continue reading
Request your trial