E.R. v. Unitedhealthcare Ins. Co.

• Decision Date: 30 March 2017
• Docket Number: 3:14-cv-1657 (CSH).
• Citation: 248 F.Supp.3d 348
• Parties: E.R., Plaintiff, v. UNITEDHEALTHCARE INSURANCE COMPANY, Defendant.
• Court: U.S. District Court — District of Connecticut

248 F.Supp.3d 348

E.R., Plaintiff,

v.UNITEDHEALTHCARE INSURANCE COMPANY, Defendant.

3:14-cv-1657 (CSH).

United States District Court, D. Connecticut.

Signed March 30, 2017

Ian O. Smith, The Law Office of Ian O. Smith, LLC, Tolland, CT, Lisa S. Kantor, Kantor & Kantor, LLP, Northridge, CA, for Plaintiff.

Michael H. Bernstein, Sedgwick LLP, New York, NY, for Defendant.

RULING ON DEFENDANT'S AND PLAINTIFF'S CROSS MOTIONS FOR SUMMARY JUDGMENT

HAIGHT, Senior District Judge:

In this action, Plaintiff E.R. brings suit against her insurer for denying coverage of residential treatment for an eating disorder. Plaintiff asserts that the denial was both arbitrary and capricious because the treatment was "medically necessary" as defined in Plaintiff's insurance policy, which is governed by the Employee Retirement Income Security Act of 1974 ("ERISA"). Plaintiff argues the treatment was "medically necessary" given Plaintiff's medical history, record and condition at the time of the denial. Plaintiff and Defendant, UnitedHealthcare Insurance Company ("United"), have each moved for summary judgment. This Ruling resolves these fully briefed cross-motions.

I. Factual Background

On January 1, 2013, Plaintiff was enrolled as a beneficiary in a UnitedHealthcare Choice Plus Plan issued to a company called I.T. Xchange Corp. Doc. 34 ¶ 3. Pursuant to the Group Enrollment Agreement between United and I.T. Xchange, United issued a Certificate of Coverage to Plaintiff that set forth the terms, limitations, conditions, and exclusions of coverage under the policy (collectively the "Policy" or "Plan"). Ex. A at 003¹ ; Doc. 34 ¶ 4.

A. Plaintiff's Policy

The Plan states that the Certificate of Coverage "is a part of the policy" providing benefits to "Covered Persons, subject to the terms conditions, exclusions, and limitations of the Policy." Ex. A at 004. The Certificate also states that the Policy includes, in addition to the Certificate, the Group Policy, Schedule of Benefits, Enrolling Group's applications, riders and amendments. Id. The Plan provides that United has "discretion" to "[i]nterpret Benefits and the other terms, limitations and exclusions set out in this Certificate , the Schedule of Benefits and any Riders and/or Amendments" as well as to "[m]ake factual determinations relating to Benefits." Id. at 008, 059. The Plan further provides that United "may delegate this discretionary authority [to determine benefits] to other persons or entities that may provide administrative services for this Benefit plan, such as claims processing" and that the "identity of the service providers and the nature of their services may be changed from time to time in [United's] discretion." Id. at 008, 059.

The Plan covers "Mental Health Services" provided by out-of-network providers so long as those services are "Covered" under the terms of the Plan. Id. at 006, 008–10, 017, 030. Mental Health Services include "those received on an inpatient basis in a Hospital or Alternate Facility, and those received on an outpatient basis in a provider's office or at an Alternate Facility," which includes "[s]ervices at a Residential Treatment Facility." Id. at 017. However, only services that are "Medically Necessary" are covered by the Plan. Id. at 012, 063, 066. A service is "Medically Necessary" if it is (1) "[p]rovided for the diagnosis, treatment, cure [sic] relief of a health condition, illness, injury or disease"; (2) "not for experimental investigational or cosmetic purposes," except as provided under "GS 38–3–255"; (3) "[n]ecessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease or its symptoms"; (4) "[w]ithin generally accepted standards of medical care in the community"; and (5) "[n]ot solely for the convenience of the Covered Person, the Covered Person's family or the provider." Id. at 066.

The Plan also provides for a "Mental Health/Substance Use Disorder Designee" who is the individual or organization designated by United "that provides or arranges Mental Health Services" for which benefits are available under the Policy. Ex. A at 066. This person or organization "determines coverage for all levels of care" related to Mental Health Services. Id. at 017. The Plan encourages the policyholders to contact their Mental Health/Substance Use Disorder Designee "for referrals to providers and coordination of care." Id.

United apparently designated United Behavioral Health ("UBH") as its Mental Health/Substance Use Disorder Designee. Ex. A at 017; Ex. B at 146, 1081. UBH made coverage decisions for Plaintiff in this case, determining the appropriate level of care. See , e.g. , Ex. B at 146–47, 1081–82. In making such decisions, UBH informed Plaintiff that it applied its own internal guidelines ("UBH Guidelines") to determine whether the level of care was "medically necessary." Id. at 146, 1081. The UBH Guidelines provide that in order for residential treatment to be provided any one of the following criteria must be met by the insured: (1) the person must be "experiencing a disturbance in mood

, affect or cognition resulting in behavior that cannot be safely managed in a less restrictive setting"; (2) "[t]here is an imminent risk that severe, multiple and/or complex pychosocial stressors will produce significant enough distress or impairment in psychological, social, occupational/educational, or other important areas of functioning to undermine treatment in a lower level of care"; or (3) the person "has a co-occurring medical disorder or substance use disorder which complicates treatment of the presenting mental health condition to the extent that treatment in a Residential Treatment Center is necessary." Id. at 1038. If one of the three criteria is met, then the insured must also meet seven other criteria for residential treatment to be necessary: (1) certain requirements for care must be met within 48 hours of admissions, (2) the person must not be at imminent risk of serious harm to self or others, (3) required psychiatric evaluations and consultations must occur at least twice per week, (4) the facility must have available all general medical services, (5) there must be collaboration to update the treatment plan so that the continued treatment "is required to prevent acute deterioration or exacerbation of the" person's current condition, (6) there must be collaboration to update a discharge plan, and (7) certain requirements exist for the discharge plan. Id. at 1038–1040.

B. Medical History of Plaintiff

Plaintiff is a nineteen-year-old woman who stated that her eating disorder began in sixth grade and that she had been diagnosed with Anorexia Nervosa

. Ex. B at 667. Her family has a history of mental illness. Id. at 668, 1132. Various intake assessments for Avalon Hills Treatment Center ("Avalon Hills") detail Plaintiff's long history battling the eating disorder.²

See, e.g. , id. at 667–670. Plaintiff's disorder "took the form of severe restriction and overexercise," she was a competitive athlete, excellent student and described herself as "very ‘competitive and perfectionistic.’ " Id. at 667. However, "socially [E.R.] has had very few close friends." Id. at 687. In 2009, at the age of twelve, Plaintiff's mother noticed that Plaintiff was restricting her caloric intake and by July of 2009 Plaintiff weighed just 75 pounds. Id. at 685. Plaintiff began the Maudsley family-based treatment program and some meals would take up to six hours to complete. Id. at 549.

Between April and June 2011, Plaintiff participated in the intensive outpatient program ("IOP") at the Renfrew Center for three days per week. Ex. B at 685–86. Renfrew determined she was not making enough progress after three months of treatment as an IOP and referred her to its day program. Id. This surprised Plaintiff and after an outburst, in which she threw a phone at someone, she was informed she was no longer welcome at the facility. Id. She was subsequently admitted to Silver Hill Hospital in Connecticut for a one week period. Id. at 686. Upon discharge, Plaintiff worked with an outpatient therapist but her weight dropped again. Id.

In December 2011, she began treatment at the Wilkins Center for Eating Disorders in Greenwich, Connecticut where she was treated until May 2012. Ex. B at 686. During that time Plaintiff's mother noted that Plaintiff's behavior got "more bizarre and she became more rigid" and Plaintiff, although not allowed to play soccer or run track, found ways to go running by lying or sneaking out and would throw out food when her parents were not looking. Id. In May 2012, Plaintiff was admitted to a residential treatment program at Klarman Eating Disorder Center at McLean Hospital in Boston, but she tried to run away prior to admission and did run away after admission. Id. As a result, the hospital would no longer treat her. Id. She was subsequently admitted to the pediatric inpatient ward at Massachusetts General Hospital in Boston where she continued to hide food and hold urine to manipulate her weight. Id. She was placed on 24–hour supervision. Id.

Upon discharge from Massachusetts General Hospital, Plaintiff was admitted to New York Presbyterian Hospital for an eighteen-day stay as an inpatient. Ex. B at 686. At one point during this stay she needed a nasogastric tube

placed, which she resisted, requiring that she be sedated for insertion. Id. Once she reached 94 pounds, she was discharged and continued treatment at Timberline Knolls Residential Treatment Center in Illinois. Id. After five weeks of treatment, benefits were denied to her and she was discharged on July 25, 2012. Id. Plaintiff thereafter returned to treatment as an outpatient at Renfrew Center from August 1, 2012 until September 14, 2012. Id. She returned to school, including playing soccer but was soon injured and could not play, which devastated her. Id.

C. Plaintiff's Admission to Avalon Hills Treatment Center

On November 14, 2012, Plaintiff was admitted...