Roibas v. EBPA, LLC
| Decision Date | 28 September 2018 |
| Docket Number | Docket No. 1:17-cv-020-NT |
| Citation | 346 F.Supp.3d 164 |
| Parties | Anxo Cereijo ROIBAS, as Assignee of Melissa True, and Melissa True, Plaintiffs, v. EBPA, LLC, d/b/a/ Employee Benefit Plan Administration, and MaineGeneral Health, Defendants. |
| Court | U.S. District Court — District of Maine |
Bradley M. Lown, Coughlin, Rainboth, Murphy and Lown, Portsmouth, NH, for Plaintiffs.
Seth W. Brewster, Edward F. Feibel, Eaton Peabody, Erica M. Johanson, Jensen Baird Gardner & Henry, Frank K.N. Chowdry, F.K.N. Chowdry Chartered, LLC, Christopher S. Lockman, Verrill Dana LLP, Portland, ME, Keith E. Glidden, Verrill Dana, LLP, Boston, MA, for Defendants.
The parties to this action dispute the terms of the MaineGeneral Health Employee Health Plan (the "Plan "), of which Plaintiff Melissa True is a beneficiary. The Plan is governed by the Employee Retirement Income Security Act ("ERISA "). This matter comes before me on cross-motions for judgment on the administrative record filed by the Plaintiffs (ECF No. 50) and by Defendant MaineGeneral Health ("MaineGeneral " or the "administrator ") (ECF No. 48). For the reasons set out below, I DENY the Plaintiffs' motion and I GRANT MaineGeneral's motion.
Plaintiff True is an employee of MaineGeneral and a beneficiary of the Plan. Plaintiff Roibas is an assignee of True's rights to reimbursement of medical expenses for services covered by the Plan. AR 327, 339.1 Defendant MaineGeneral is the Plan administrator, responsible for selecting the terms of the Plan and interpreting them. AR 93. Defendant EBPA is the third party administrator of the Plan and conducts the administrative, "ministerial," operations, such as processing claims. See AR 93, 102.2
In August of 2014, Melissa True entered into a "Gestational Carrier Agreement" (the "Agreement ") with intended parents Anxo Cereijo Roibas and Szczepan Wojciech (the "Intended Parents "). AR 329. The Agreement provided that True would "carry and deliver the child(ren) of the Intended Parents ... through medical procedures using assisted reproductive technology." AR 329-30. True was to be compensated for serving as a gestational carrier. AR 341-42. The Intended Parents also committed to "pay all medical expenses which are reasonably and directly related to the pregnancy and birth which are not covered by [True's ] health insurance. " AR 339 (emphasis added). True agreed to submit claims for all pregnancy-related medical expenses to her health insurer and to assist the Intended Parents in seeking to have the expenses covered, including through "all available administrative and legal remedies" if the insurer denied the claims. AR 331-32.
AR 027. The next section of the Plan is titled, "General Medical Exclusions and Limitations," and lists, "[e]xpenses for surrogacy." AR 032.
True became pregnant and gave birth, in accordance with the Agreement. Medical expenses from the pregnancy and delivery were submitted to EBPA. AR 110-84; 299. EBPA initially approved, and paid for, some expenses related to True's pregnancy. See AR 110-21, 127-29, 134-36, 146-52, 299. Upon review of True's claims and medical records, a utilization review nurse employed by EBPA identified that True was a surrogate mother and that, accordingly, her claims should be denied because they were not covered by the Plan. AR 299.
True appealed the denial of her claims in a letter to EBPA dated January 20, 2016. She stated that the "main[ ]" basis of her appeal was that she "was informed there would not be any issues related to claims for prenatal care" during a call to EBPA in January 2015, in which she inquired "to determine if EBPA had maternity coverage for surrogacy related pregnancies." AR 301. True claimed in the letter that she was informed on that call that "there was no exclusion, [and] that pregnancy was a covered diagnosis." AR 301. After communicating with MaineGeneral, EBPA denied True's appeal, claiming that it had no record of the phone call that she referenced. AR 302. EBPA further informed her that "[v]erification can only be documented in your file when you had actual medical coverage" and that "a verification of benefits is not a guarantee of coverage." AR 302.
True, with the assistance of counsel, filed a second administrative appeal in April of 2016, arguing that "[t]he Plan does not distinguish between pregnancies based upon why the woman became pregnant." AR 304. True also argued that she served as a gestational carrier, rather than a surrogate, that "[t]he Plan does not state that expenses for a ‘gestational carrier’ are excluded," and that any ambiguity in the Plan should be construed in favor of coverage. AR 305. EBPA denied this appeal in a letter dated May 4, 2016. AR 318-19. The basis for the denial was that "True's denied claims fall under the surrogacy exclusion as outlined in the [Plan]," and that, to the extent that True was a gestational carrier and not a surrogate, the Plan excludes "[e]xpenses for any service, procedure or supply not listed as a covered service in the [P]lan." AR 318.
Roibas filed a Complaint in this court on January 19, 2017. Roibas claimed standing to challenge the administrator's denial of claims as True's assignee. Compl. (ECF No. 1). True was added as a plaintiff to the action on August 3, 2017. Second Am. Compl. (ECF No. 35). The Plaintiffs and MaineGeneral then filed the instant motions for judgment on the record.3
"By cross-moving for judgment based on the administrative record filed in this case, the parties empower the court to adjudicate this case based on that record, resolving any factual as well as legal disputes." Ellis v. Unum Life Ins. Co. of Am. , No. 2:13-CV-00080-JAW, 2014 WL 235212, at *2 (D. Me. Jan. 22, 2014) (citing Bhd. of Locomotive Eng'rs v. Springfield Terminal Ry. Co. , 210 F.3d 18, 31 (1st Cir. 2000) ).
The parties have stipulated that the applicable standard of review for MaineGeneral's decision to deny True's benefit claims is whether that decision was "arbitrary, capricious, or an abuse of discretion ... as established by the Plan and Firestone Tire and Rubber Co. v. Bruch , [489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989) ] and its progeny."4 Consent Mot. to Am. Scheduling Order ¶ 5 (ECF No. 42).5 The First Circuit has noted that in this context, "the arbitrary and capricious standard is functionally equivalent to the abuse of discretion standard."
Dutkewych v. Standard Ins. Co. , 781 F.3d 623, 633 n.6 (1st Cir. 2015). Under that standard, I "need not decide the ‘best reading’ of the Plan." O'Shea through O'Shea v. UPS Ret. Plan , 837 F.3d 67, 73 (1st Cir. 2016). Instead, I must evaluate whether the administrator's decision "is reasonable and supported by substantial evidence on the record as a whole." Doe v. Standard Ins. Co. , 852 F.3d 118, 123 (1st Cir. 2017). I may not disturb the administrator's reasonable interpretation even if I would have come to a different conclusion or if the Plaintiffs have offered a competing reasonable interpretation. See Stamp v. Metro. Life Ins. Co. , 531 F.3d 84, 94 (1st Cir. 2008) ; see also Ho-Rath v. Tufts Associated Health Maint. Org., Inc. , No. CA 12-546 S, 2013 WL 5924428, at *2 (D.R.I. Oct. 31, 2013) ; Massey v. Stanley-Bostitch, Inc. , 255 F.Supp.2d 7, 11 (D.R.I. 2003).6
The parties have presented three issues for my consideration: First, whether Plaintiff Roibas has standing to challenge the administrator's interpretation; second, whether MaineGeneral's decision to deny True's claims on the grounds that her pregnancy expenses were "expenses for surrogacy" was arbitrary and capricious; and third, whether the Plaintiffs or the Defendants are entitled to attorneys' fees on this motion. Because I ultimately conclude that the Defendants prevail on the merits, and because Defendants do not contend that Plaintiff True lacks standing, I proceed directly to the merits.7
"Neither the Supreme Court nor [the First Circuit] has ‘spoken directly to how courts should assess whether an administrator's construction of a plan term is so unreasonable as to constitute an abuse of discretion.’ " Dutkewych , 781 F.3d at 636 n. 8 (quoting D & H Therapy Assocs., LLC v. Boston Mut. Life Ins. Co. , 640 F.3d 27, 36 (1st Cir. 2011) ). In D & H Therapy , the First Circuit surveyed, without adopting, guidelines used by other Circuits. D & H Therapy Assocs. , 640 F.3d at 37-38. Boiled down, most of the guiding factors used in other jurisdictions involve assessing whether the administrator's construction (1) runs contrary to the plan's plain language; (2) squares with the general purpose of the plan; (3) renders the plan internally inconsistent or leaves another plan provision meaningless; and (4) has been consistently applied. D & H Therapy Assocs. , 640 F.3d at 38. While the First Circuit seems to prefer a case by case analysis of whether a plan administrator has abused its discretion, at least some of the factors followed in other jurisdictions have been used by the First Circuit. See Colby v. Union Sec. Ins. Co. & Mgmt. Co. for Merrimack Anesthesia Assocs. Long Term Disability Plan , 705 F.3d 58, 65 (1st Cir. 2013) (); Glista v. Unum Life Ins. Co. of Am. , 378 F.3d 113, 124 (1st Cir. 2004) (...
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