Billy Hooper v. Demco, Incorporated

37 F.3d 287, 18 Employee Benefits Cas. (BNA) 2153, 1994 U.S. App. LEXIS 27431, 1994 WL 529940
CourtCourt of Appeals for the Seventh Circuit
DecidedSeptember 28, 1994
Docket93-3710
StatusPublished
Cited by31 cases

This text of 37 F.3d 287 (Billy Hooper v. Demco, Incorporated) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Billy Hooper v. Demco, Incorporated, 37 F.3d 287, 18 Employee Benefits Cas. (BNA) 2153, 1994 U.S. App. LEXIS 27431, 1994 WL 529940 (7th Cir. 1994).

Opinions

COFFEY, Circuit Judge.

The plaintiff, Billy Hooper,1 brought an action against his former employer, Demco, Inc. (“Demco”), under the Employee Retirement Ineome Security Act (“ERISA”), 29 U.S.C. § 1132(a)(1)(B) and (a)(3), claiming that the health plan administered by Demco had capriciously denied coverage for his HDC-ABMT cancer treatment.2 Shortly after Hooper filed suit against Demco, the parties entered into a settlement agreement in which various charitable organizations and Demco employees agreed to provide for the costs of Hooper’s treatment as part of the settlement. After the settlement was reached, the suit was dismissed with prejudice. Thereafter, Hooper’s counsel, claiming that Hooper was the prevailing party, filed a petition for attorney’s fees as provided for under ERISA. 29 U.S.C. § 1132(g)(1). Both sides submitted briefs and supporting affidavits on the attorney’s fees question. The court denied the plaintiff’s request for fees ruling that based on the record, the defendant’s position in denying coverage for this type of investigational and experimental cancer treatment, was “substantially justified.” We affirm.

I. BACKGROUND

In 1990, Billy Hooper, an employee of the defendant, Demco, was diagnosed with multiple myeloma,3 a form of cancer that attacks the bone marrow and has a high mortality rate. In the early treatment stages, Hooper’s chemotherapy treatment proved effective, and the disease went into remission, but recurred in the fall of 1992. At this time, Hooper’s doctors recommended High-Dose Chemotherapy coupled with an Autologous Bone Marrow Transplant (“HDC-ABMT”). In two recent cases, this court has discussed the HDC-ABMT treatment in detail. See Bechtold v. Physicians Health Plan, 19 F.3d 322, 324 (7th Cir.1994) and Fuja v. Benefit Trust Life Ins. Co., 18 F.3d 1405, 1407 (7th Cir.1994). We stated that HDC-ABMT is a two-step procedure in which the physicians extract (“harvest”) the bone marrow cells [289]*289from the patient’s body and temporarily place them in frozen storage. Next, the patient undergoes a near-lethal cycle of high-dose chemotherapy in an attempt to destroy the cancer cells. Because the high-dose chemotherapy also attacks the bone marrow cells, it is necessary to withdraw some of the patient’s bone marrow prior to undergoing the high-dose chemotherapy procedure. Without initially removing a portion of the patient’s bone marrow cells, the high-dose chemotherapy would be lethal because of its myeloblative effect (high-dose chemotherapy destroys bone marrow cells which produce blood cells (red and white as well as platelets) rendering the patient highly susceptible to infection and possible death). After completing the administration of the high-dose chemotherapy, the patient’s own (“autolo-gous”) stored marrow is reinfused intravenously into the blood stream to reheve the patient from the toxic effects of the chemotherapy. HDC-ABMT has proven effective in treating certain cancerous blood diseases such as leukemia and Hodgkin’s disease. To date HDC-ABMT’s effectiveness has not been universally established and thus not universally accepted as a usual and normal treatment for solid-type tumors, (as in Fuja and Bechtold), or for multiple myeloma.

The Demco Health Plan

Demco, has a self-funded health plan (the “Demco Plan”) overseen by an independent professional claims administrator, the Traveler’s Plan Administrator (“TPA”). TPA’s job is to evaluate each case presented to the plan and determine whether the proposed treatment is covered by provisions in the Demco plan. TPA had approved payment of all of Mr. Hooper’s cancer treatments and proce-dtires up to the request for approval of and reimbursement for the HDC-ABMT.

The Demco plan provided in relevant part: “General Exclusions and Limitations Unless specified otherwise in the Plan, covered charges will not include and no benefit shall be payable for: ... Experimental or Investigative Treatment, or treatment, service or supply not recognized as generally accepted and appropriate in the treatment of the condition by the American Medical Association.”4

Under the clear terms of the Demco plan, TPA could not authorize funds for any procedure that was “experimental” or “investigative.” TPA contacted UMAC, Inc. (“UMAC”), an independent medical review organization, to determine whether HDC-ABMT was investigative or experimental and thus not covered under the plan. UMAC advised that only a small number of multiple myeloma patients had been treated with bone marrow transplant and high-dose chemotherapy and further advised that the procedure was not in widespread use,5 nor was it generally accepted in the medical research arena as a proven and effective treatment for multiple myeloma.6 After its own research and evaluation, UMAC concluded that HDC-ABMT as a treatment for multiple myeloma was “experimental” and “investigate” as defined in the Demco plan.

TPA sought a second opinion from the Medical Review Institute of America (“MRIA”), another independent medical review organization. MRIA found, after a review of the current medical writing and research data available, that HDC-ABMT was not a generally accepted treatment for multiple myeloma. MRIA further determined that there was insufficient documentation of [290]*290the effectiveness of HDC-ABMT and insufficient length of follow-up studies, to conclude that HDC-ABMT was an effective treatment for this type of cancer. In the absence of medical and scientific documentation that HDC-ABMT would either prolong Hooper’s life or control the spread of the disease, MRIA concluded that the HDC-ABMT procedure for multiple myeloma was still deemed to be experimental and “not generally accepted as a standard medical treatment” for multiple myeloma under the terms of the Demco plan. Both UMAC and MRIA are considered by TPA to be reputable organizations which conduct independent evaluations of medical treatments and procedures. The opinions of these organizations are frequently relied on by health plan administrators and organizations to determine coverage questions.

On May 25, 1993, TPA sent written notification to Hooper stating that based on the independent reviews of both UMAC and MRIA, the Demco Plan would not pay for HDC-ABMT because TPA concluded that the HDC-ABMT treatment was still considered to be experimental and in the investigative stage of development.

One month later, in a letter dated June 23, 1998, Hooper’s physician, Dr. Longo, requested a re-review of TPA’s decision. Dr. Longo provided TPA with various medical literature discussing the most current studies based on the usage of HDC-ABMT and requested that TPA reconsider its decision in light of these new studies. After review, TPA concluded that the literature failed to support Hooper’s claim that HDC-ABMT was generally accepted as a standard medical treatment, but nonetheless, TPA turned the claim and the new information over to UMAC for its evaluation.

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Bluebook (online)
37 F.3d 287, 18 Employee Benefits Cas. (BNA) 2153, 1994 U.S. App. LEXIS 27431, 1994 WL 529940, Counsel Stack Legal Research, https://law.counselstack.com/opinion/billy-hooper-v-demco-incorporated-ca7-1994.