DeMarinis v. Anthem Insurance Companies, Inc.

CourtDistrict Court, M.D. Pennsylvania
DecidedMarch 7, 2025
Docket3:20-cv-00713
StatusUnknown

This text of DeMarinis v. Anthem Insurance Companies, Inc. (DeMarinis v. Anthem Insurance Companies, Inc.) is published on Counsel Stack Legal Research, covering District Court, M.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
DeMarinis v. Anthem Insurance Companies, Inc., (M.D. Pa. 2025).

Opinion

THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA CHRIS DEMARINIS, individually and as guardian of D.D., : CIVIL ACTION NO. 3:20-CV-713 : (JUDGE MARIANI) Plaintiff, Vv. ANTHEM INSURANCE COMPANIES, : INC., d/b/a ANTHEM BLUE CROSS AND BLUE SHIELD and ABC : CORPORATIONS 1-10, Defendant. : MEMORANDUM OPINION |. INTRODUCTION Plaintiff's Motion for an Award of Attorney’s Fees and Costs (Doc. 63) is pending before the Court. Plaintiff moves for an award of attorney’s fees and taxable costs pursuant to 29 U.S.C. § 1132(g)(1), the provision of the Employee Retirement Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001, et seg., which addresses the award of attorney’s fees and costs. (/d. at 1.) Plaintiff claims entitlement to fees and costs based on the Court's partial grant of summary judgment in his favor. (Doc. 63-1 at 1.) He alternatively seeks attorney's fees on a contingency basis, the amount of which is “pending” and on an hourly basis calculated to be $51,704.60. (/d. at 12.) Plaintiff also requests an award of taxable costs in the amount of $2,056.52.63. (/d.) Defendant Anthem Insurance Companies, Inc. (“Anthem” “Defendant’) responds that Plaintiff has not demonstrated that he qualifies for an award of

fees and costs under ERISA, an hourly calculation rather than contingency fee is appropriate if he were entitled to fees, and any award should be reduced because Plaintiff achieved only partial success and submitted improper entries for reimbursement. (Doc. 66 at 1.) Plaintiff did not file a reply brief and the time for doing so has passed. Therefore, Plaintiff's Motion is ripe for disposition. For the reasons set forth below, the Court will grant Plaintiffs Motion in part. Il. BACKGROUND Plaintiff filed this action on April 30, 2020, claiming violations of ERISA, specifically 29 U.S.C. §§ 1109 and 1132(a)(1)(B). Plaintiff filed the action after Defendant denied

coverage for a substantial portion of the cost of his son’s treatment at the Kennedy Krieger Institute (“KKI”) inpatient Neurobehavioral Unit (“NBU”). (Doc. 1.) At the time the Complaint was filed, D.D., Plaintiffs minor son, was sixteen years old and had a diagnosis of “severe intellectual disability, Autism Spectrum Disorder, Disruptive Behavior Disorder, Obsessive- Compulsive Disorder, seizures, Macrocephaly, and Hypokinetic syndrome.” (/d. § 13.) With Anthem’s approval, D.D. had been admitted to KK! on May 1, 2019, and on May 8, 2019, Defendant denied continuation of coverage. (Id. J 34.) Defendant continued to deny coverage through the appeals process. (/d. J] 35-42.) On July 9, 2019, KKI submitted a request for independent external review. (/d. 43.) On September 3, 2019, the assigned reviewer, Advanced Medical Reviews (“AMR’), issued a letter and Peer Reviewer Final Report upholding Anthem’s decision that continued treatment at KKI was not medically

necessary from May 8, 2019, forward. (/d. ] 50.) Plaintiff requested that the Court require Defendant to cover the cost of D.D.’s treatment at KKI’s NBU program from May 8, 2019, to October 24, 2019, in the amount of $459,318 and reimburse Plaintiff for the reasonable attorneys’ fees and costs incurred in this action. (Doc. 1 at 11.) Plaintiff's Motion for Summary Judgment (Doc. 33) was filed on March 24, 2021. Plaintiff sought summary judgment based on the contention that Anthem ignored the opinions of D.D.’s treating physicians and common sense when it determined that D.D.’s treatment at KKI was not medically necessary as of May 8, 2019. (Doc. 38 at 2.) Plaintiff asserted that {clontrary to Anthem’s determination, . . . the medical necessity of D.D.’s treatment at KKI did not end on May 8, 2019. There is significant evidence in the record from D.D.’s behavioral and medical providers that he continued to require inpatient treatment and benefited from treatment at KKI following Anthem’s denial. Premature discharge and interruption in treatment would have placed D.D. and others at risk for injury, and likely would have resulted in re-hospitalization. Further, there is no indication that the experts retained by Anthem and/or its medical directors involved in the appeal process had any expertise in the treatment of severe behavioral dysfunction (notably self-injurious behavior) in children and adolescents with autism and/or intellectual disability. What is certain is that Anthem’s experts did not examine D.D. or meet with his parents or medical providers. Accordingly, Anthem’s denial of plaintiff's claim should be overturned as it is not supported by substantial evidence, erroneous as a matter of law, not made in good faith and in violation of ERISA. (Doc. 38 at 2.)

Defendant asserted that summary judgement in its favor was warranted because it

properly determined that D.D.’s continued treatment was not medically necessary and denied coverage on this basis. (See, e.g., Doc. 47 at 1.) On April 10, 2024, the Court issued a Memorandum Opinion (Doc. 61) and Order (Doc. 62) granting Plaintiff's Motion for Summary Judgment (Doc. 33) in part and denying Defendant’s Cross Motion for Summary Judgment (Doc. 45). The Court concluded that Plaintiff was entitled to payment of benefits for the period of May 8, 2019, through July 7, 2019, and for evaluation of benefits consistent with the Court's Memorandum Opinion for the period of July 8, 2019, through October 24, 2019, and appropriate payment of benefits for that period. (Doc. 61 at 95.) Employing the “arbitrary and capricious” standard of review,' the Court's decision

was based on (1) findings that numerous recognized procedural anomalies suggested that Anthem’s decision was arbitrary and capricious; and (2) the lack of substantial evidence to support Anthem’s decision that continued care for D.D. was not medically necessary further supported a finding that its determination not to continue coverage was arbitrary and capricious. (Doc. 61 at 39-81.) The anomalies identified included Anthem’s reversal of its position, inconsistent treatment of facts, inadequate consideration of opinion evidence,

' If a plan does not grant discretion to the fiduciary, “then a court reviews an adverse benefit determination de novo.” Noga v. Fulton Fin. Corp. Emp. Benefit Plan, 19 F.4th 264, 272 (3d Cir. 2021) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). But if a plan does confer discretionary authority on a fiduciary decision-maker, then a court reviews an adverse benefit determination for an abuse of discretion under the arbitrary-and-capricious standard.” /d. (citing Firestone, 489 U.S. at 115; McCann v. Unum Provident, 907 F.3d 130, 147 (3d Cir. 2018)). The parties agreed that the arbitrary- and-capricious standard applied in this case. (Doc. 61 at 37.)

analysis of all relevant diagnoses, and review independence. (/d.

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Bluebook (online)
DeMarinis v. Anthem Insurance Companies, Inc., Counsel Stack Legal Research, https://law.counselstack.com/opinion/demarinis-v-anthem-insurance-companies-inc-pamd-2025.