Dragu v. Motion Picture Industry Health Plan for Active Participants

144 F. Supp. 3d 1097, 2015 U.S. Dist. LEXIS 157614, 2015 WL 7274202
CourtDistrict Court, N.D. California
DecidedNovember 16, 2015
DocketCase No. 14-cv-04268-RS
StatusPublished
Cited by3 cases

This text of 144 F. Supp. 3d 1097 (Dragu v. Motion Picture Industry Health Plan for Active Participants) is published on Counsel Stack Legal Research, covering District Court, N.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Dragu v. Motion Picture Industry Health Plan for Active Participants, 144 F. Supp. 3d 1097, 2015 U.S. Dist. LEXIS 157614, 2015 WL 7274202 (N.D. Cal. 2015).

Opinion

ORDER GRANTING PLAINTIFF’S AND DENYING DEFENDANT’S MOTIONS FOR SUMMARY JUDGMENT

RICHARD SEEBORG, District Judge

I. INTRODUCTION

Plaintiff Elise Dragu mangled her jaw, mouth, teeth, and gums when she tumbled down a rocky creek while hiking in Northern California. She sought medical treatment for her various injuries from oral surgeon, Dr. Robert A. Shuken, D.D.S., who recommended extracting the damaged teeth, inserting bone grafts where possible, implanting fixtures for implantation of abutments and crowns, and — lastly — installing abutments and crowns as replacements for the missing teeth. Dragu requested coverage for the medical procedures from her medical benefit plan, Defendant Motion Picture Industry Health Plan for Active Participants (“the Plan”), which is subject to the requirements of the Employee Retirement Income and Security Act (“ERISA”), 29 U.S;C.§ 1001 et seq.

The Plan initially denied coverage for dental implants, including the implantation of fixtures and placement of abutments and crowns, on the basis that “Dental services are not covered under the Plan.” Keenley Decl. Ex. 4 at 532.1 Dragu appealed the adverse determination to the Plan’s Benefits/Appeals Committee. After reviewing the appeal, the Benefits/Appeals Committee paid Dr. Shuken for the installation of fixtures at a reimbursement rate of 50%, which was the rate available to out-of-network providers under the terms of the 2013 plan. With respect to Dragu’s request for medical coverage for the placement of crowns and abutments, the Plan [1103]*1103offered a different reason to deny the claim: “Dental implants may be covered in cases of trauma, ablative surgery or congenital anomalies. Prosthetic rehabilitation of dental implants including abutments and crowns are not covered under the medical benefit.” Keenley Decl. Ex. 7 at 460. In her motion for summary judgment, Dragu contends that the Plan wrongfully denied coverage for the crowns and abutments and reimbursed Dr. Shuken at a lower rate than was required by the applicable plan. The Plan argues that its interpretation of the medical coverage agreement was proper and that it is entitled to attorney fees.

The Plan misinterpreted the plain language of the medical benefit plan when it denied Dragu coverage for the initial placement of abutments and crowns and reimbursed Dr. Shuken at the lower rate as required by the plain language of the medical benefit agreement. That interpretation of the terms of the plan was an abuse of discretion. Accordingly, Dragu’s motion for summary judgment is granted; the Plan’s is denied as is the Plan’s request for attorney’s fees.

II. FACTS AND PROCEDURAL HISTORY

While hiking in forests of the north coast of California, Dragu suffered terrible injuries to her wrists, body, face, and mouth after falling into a steep river embankment. As a result of the fall, Dragu’s jaw and teeth were fractured, and some of her teeth were torn from the roots or pushed out of position. After undergoing jaw surgery, Dragu sought treatment for her mouth and teeth from Dr. Shu'ken, who recommended that she undergo multiple surgeries, including the implantation of fixtures, and affixation of prosthetic teeth — abutments and crowns. To cover the expenses of the extensive mouth and jaw procedures, Dragu submitted claims for benefits to the Plan of which she is a beneficiary. The Plan is a self-funded group health plan which exists for the purpose of providing health and welfare benefits to eligible participants and their spouses and dependents.

A. Dragu’s Treatment with Dr. Shuken: Teeth Removal and Installation of Fixures

In December 2012, after Dragu had been able to heal and recover, Dr. Shuken determined that six of her teeth needed to be removed. Before proceeding with the surgery, Dr. Shuken submitted a pre-ap-proval authorization request, seeking authorization for approval to remove Dragu’s unsalvageable teeth surgically, insert bone grafts, and administer anesthesia. Included with the pre-authorization documents was the long-term treatment plan, which envisioned work with a prosthodontist to insert implants to replace .the teeth. On Februaryl, 2013, before the Plan responded to the pre-authorization request, Dragu underwent the tooth extraction surgery; Dr. Shuken placed bone grafts into her jaw where needed. Soon thereafter, the Plan approved Dr. Shuken’s pre-approval request for surgical removal of teeth, bone replacement grafts, and anesthesia.

Happily, Dragu healed and went forward with the next phase of her treatment plan: the installation of fixtures. Again, on August 29, 2013, Dr. Shuken submitted a pre-approval authorization request for endosteal surgical implants — insertion of posts to anchor the crowns and abutments. Two weeks later, Dr. Shuken installed three fixtures successfully. On September 16, 2013, he submitted a claim for payment for the successful procedure.

B. The Plan Changes the Terms of the Summary Plan Descriptions (“SPDs”)

In the meantime, the Plan adopted and implemented a new SPD to go into effect [1104]*1104on October 1, 2013, which superseded the 2007 SPD. The 2013 SPD became “effective for expenses incurred on or after October 1, 2013..:Keenley Decl. Ex. 10 at 157. Of particular importance was the change in coverage for “dental implants.” Both the 2007 and 2013 SPDs did not provide coverage for “dental treatments” as a medical benefit with the exception of certain dental treatments for the following medical diagnoses: “myalgia, myositis, migraine, trigeminal neuralgia, sleep apnea, and temporomandibular joint disorder.” Compare Keenley Decl. Ex. 11 at 372 (2007 SPD), with id. Ex. 10 at 216 (2013 SPD). The 2007 SPD excluded dental implants from the services covered under the medical plan “except where there is no other dental alternative.” Keenley Decl. Ex. 11 at 380. In contrast, the 2013 SPD provided coverage for dental implants “in cases of trauma, ablative surgery or congenital anomalies. Prosthetic rehabilitation of dental implants including abutments and crowns are not covered under the medical benefit.” Id. Ex. 10 at 217.

C. Dragu’s Treatment with Dr. Par-vizpour: Placement of Abutments and Crowns

In fall 2013, following the successful fixture implantation, Dragu began her treatment with the prosthodontist, Dr. Shahariar Parvizpour, who submitted a pre-authorization request on October 31, 2013, for the placement of abutments and crowns into the fixtures. Dragu wanted to begin that procedure in November 2013, but she delayed the procedure to await the Plan’s response to Dr. Parvizpour’s pre-authorization request. Eventually, Dragu decided to pay for the procedure out of pocket and seek reimbursement. She underwent several procedures to install abutments and crowns in March, April, and June 2014.

D. Dragu’s Administrative Appeal of the Adverse Benefits Determinations

On November 12, 2013, the Plan denied Dr. Shuken’s pre-authorization request for the fixture implantation because “[djental services are not covered under the Plan.” Keenley Decl. Ex. 4. Dissatisfied with this response, on January 17, 2014, Dragu filed an appeal with the Benefits/Appeals Committee of the denial for fixture implantation seeking coverage for “all medically necessary procedures” for reconstruction of her mouth.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
144 F. Supp. 3d 1097, 2015 U.S. Dist. LEXIS 157614, 2015 WL 7274202, Counsel Stack Legal Research, https://law.counselstack.com/opinion/dragu-v-motion-picture-industry-health-plan-for-active-participants-cand-2015.