Franzese v. United Health Care/Oxford

232 F. Supp. 3d 267, 2017 U.S. Dist. LEXIS 58993, 2017 WL 1325368
CourtDistrict Court, E.D. New York
DecidedJanuary 5, 2017
Docket14-cv-1902 (SJF)(AKT)
StatusPublished
Cited by4 cases

This text of 232 F. Supp. 3d 267 (Franzese v. United Health Care/Oxford) is published on Counsel Stack Legal Research, covering District Court, E.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Franzese v. United Health Care/Oxford, 232 F. Supp. 3d 267, 2017 U.S. Dist. LEXIS 58993, 2017 WL 1325368 (E.D.N.Y. 2017).

Opinion

OPINION AND ORDER

FEUERSTEIN, District Judge:

Plaintiffs Robert Franzese and Elizabeth Franzese, as the parents and legal guardians of Robert Franzese Jr., a disabled adult (collectively, “Plaintiffs”), commenced this action against Defendant United Health Care/Oxford (“Defendant” or “Oxford”) seeking to recover medical benefits pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1144(a). See Docket Entry (“DE”) [1]. Presently before the Court is Defendant’s motion for summary judgment pursuant to Fed. R. Civ. P. 56, which Plaintiffs oppose. DE [41], [41-21]. For the reasons set forth herein, Oxford’s motion is granted in part and denied in part.

I. BACKGROUND

A. Factual Background1

1. The Parties and Relevant Insurance Coverage

Plaintiff Robert Franzese Jr. (“Bobby”) has suffered from a chronic lung disease known as Bronchopulmonary Dysplasia (“BPD”) and multiple related conditions since birth. Pis.’ 56.1 Stmt. ¶ 1. As a result of his condition, Bobby remained at the Stony Brook University Hospital for the first two (2) years of his life. Id. According to Plaintiffs, “only a very small number of physicians have ever treated the condition and many have never heard of it.” Compl., DE [1], ¶ 14. Since leaving the hospital approximately thirty (30) years ago, Bobby has required and received in-home nursing care twenty-four (24) hours a day, seven (7) days a week. Id. at ¶ 18; see also Pis.’ 56.1 Stmt. ¶ 1.

It is undisputed that Bobby is a covered dependent under a group health insurance policy that Defendant Oxford issued to non-party Motherly Love Home Care Services, Inc. (“Motherly Love”) under group number ML19597 (the “Plan”). Pis.’ 56.1 Stmt. ¶¶ 4-7. Plaintiffs Robert Franzese (“Robert”) and Elizabeth Franzese (“Elizabeth”) own Motherly Love, and are named beneficiaries under the Plan. Id. at ¶ 3. The Plan is governed.by ERISA and incorporates, inter alia: (i) a Certificate of Coverage (the “Certificate”), which describes the benefits that are available to covered dependents under the Plan; and (ii) a Schedule of Benefits (the “Schedule of Benefits”), which describes the “copay-ments, deductibles, coinsurance, out-of-pocket máximums, preauthorization requirements, and other limits on covered services.” Id. at ¶¶ 6, 8; see also Administrative Record (“Tr.”), DE [41-2]-[41-8], at 1-15, 22, 31.

[271]*2712. Terms of the Oxford Plan

The Certificate provides that Oxford “do[es] not cover services that are not listed in [the] Certificate as being covered,” and that covered dependents “receive covered services ... only when the covered service is: medically necessary; provided by a participating provider for in-network coverage; listed as a covered service; not in excess of any benefit limitations described in the Schedule of Benefits ... ; and received while [the] Certificate is in force.” Tr. 33, 79. Pursuant to the Certificate, “covered services” are the “medically necessary services paid for or arranged for [the member] by [Oxford] under the terms and conditions of [the] Certificate.” Id. at 26. The Certificate further provides that certain covered services require “preauthorization,” which is defined as a “decision by [Oxford] prior to [the member’s] receipt of a covered service, procedure, treatment plan, device, or prescription drug that the covered service, treatment plan, device, or prescription drug is medically necessary.” Id. at 30, 33. Oxford may base its decision of whether a covered service is medically necessary upon:

[the member’s] medical records; [Oxford’s] medical policies and clinical guidelines; medical opinions of a professional society, peer review committee or other groups of physicians; reports in peer-reviewed medical literature; reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data; professional standards of safety and effectiveness, which are generally-recognized in the United States for diagnosis, care, or treatment; the opinion of health care professionals in the generally-recognized health specialty involved; and the opinion of the attending providers, which have credence but do not overrule contrary opinions.

Id. at 34.

Relevant for purposes of Plaintiffs’ claims, “home health care” is a covered service under the Plan. Id. at 49, 50. The Certificate states:

We cover care provided in your home by a home health agency certified or licensed by the appropriate state agency. The care must be provided pursuant to your physician’s written treatment plan and must be in lieu of hospitalization or confinement in -a skilled nursing facility. Home care includes (i) part time or intermittent nursing care by or under the supervision of a registered professional nurse (RN), (ii) part-time or intermittent services of a home health aide, (iii) physical, occupational, or speech therapy provided by the home health agency, and (iv) medical supplies, drugs, and medications prescribed by a physician, and laboratory services by or on behalf of the home health agency to the extent such items would have been covered during a hospitalization or confinement in a skilled nursing facility.

Id. Coverage for home health care services requires preauthorization and is limited to forty (40) visits per calendar year. Id. at 50. The Certificate neither lists “private duty nursing” as a covered service nor specifically identifies private duty nursing as a policy exclusion. Id. at 57-59. However, pursuant to a Private Duty Nursing Clinical Policy (the “Private Duty Nursing Policy”) applicable to “Oxford Commercial plan membership,” private duty nursing “is a benefit exclusion unless specifically noted otherwise .....” Id. at 367-72.

3. Plaintiffs’ Preauthorization Request

On January 29, 2014, Elizabeth requested preauthorization for private duty nurs[272]*272ing services for Bobby.2 Pis.’ 56.1 Stmt. ¶ 17. On January 30, 2014, Oxford requested additional clinical documentation from Motherly Love, including: (i) a letter of medical necessity; (ii) Bobby’s plan of treatment, including the number of days and hours for which Motherly Love sought private duty nursing services; (iii) documentation related to Bobby’s last doctor’s visit; (iv) nursing notes documenting Bobby’s four (4) most recent weeks of care and the most current supervisor’s review; (v) a current Home Health Certification and Plan of Care; (vi) medical and treatment sheets; (vii) evidence of teaching provided to caregivers; (viii) identification of other medical and therapeutic disciplines providing services, including occupational therapists, physical therapists, speech thera-, pists, social workers, and home health aides; and (ix) notes from Bobby’s consulting physician and specialists, if any, with whom Bobby treated. Id. at ¶ 18. On February 6, 2014, Motherly Love submitted: (i) a January 30, 2014 letter from Dr.

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232 F. Supp. 3d 267, 2017 U.S. Dist. LEXIS 58993, 2017 WL 1325368, Counsel Stack Legal Research, https://law.counselstack.com/opinion/franzese-v-united-health-careoxford-nyed-2017.