Goldstein v. Aetna Life Insurance Company

District Court, D. Delaware·Decided March 24, 2021·No. 1:19-cv-02188·Unknown

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE PAUL R. GOLDSTEIN, ) ) Plaintiff, ) ) v. ) Civil Action No. 19-2188-CFC-SRF ) AETNA LIFE INSURANCE CO. and ) SANOFI-AVENTIS U.S. LLC, ) ) Defendants. )

REPORT AND RECOMMENDATION I. INTRODUCTION On November 25, 2019, Paul R. Goldstein (“Plaintiff” or “Mr. Goldstein”), filed this action against Aetna Life Insurance Company (“Aetna”) and Sanofi-Aventis U.S. LLC (“Sanofi,” together with Aetna, “Defendants”) pursuant to the Employment Retirement Income Security Act of 1974 (“ERISA”) 29 U.S.C. § 1001 et seq. (D.I. 1) Mr. Goldstein was previously employed by Sanofi. (D.I. 18 at 2) Mr. Goldstein is a member of the “Sterling Medicare Prime Salaried & Hourly Non-Union Retiree $250,000 – Traditional Medical Plan” (“the Plan”). (D.I. 19 at 1) Sanofi is the administrator of the Plan, which is self-funded by a Sanofi employer fund. (Id. at 3, 82, 88) Aetna provides third party administrative services under the Plan. (Id. at 2–3) Mr. Goldstein asserts that Aetna abused its discretion by insufficiently paying his claims for reimbursement of a portion of the out-of-pocket costs he paid for home health care services for himself and his wife, Marsha Goldstein. (D.I. 1) Currently before the court is Mr. Goldstein’s “Opening Brief,” which the court construes as a motion for summary judgment.1 (D.I. 7)

1 Motions for summary judgment and any opening briefs and affidavits in support thereof were due to be served and filed on or before June 11, 2020. (D.I. 6 at ¶ 3) Plaintiff’s opening brief was timely filed on June 10, 2020. (D.I. 7) The court construes his opening brief as a motion for The court has jurisdiction pursuant to 28 U.S.C. § 1331 and 29 U.S.C. § 1132(e). For the reasons set forth below, I recommend that the court DENY Mr. Goldstein’s motion for summary judgment and enter judgment in favor of Defendants.2 II. BACKGROUND

A. Plan Details The Plan offers coverage to members for services “provided by a home health care agency in the home.” (D.I. 19 at 19–20) The Plan defines home health care agency as “[a]n agency licensed, certified or otherwise authorized by applicable state and federal laws to provide home health care services, such as skilled nursing and other therapeutic services.” (Id. at 72) The Plan includes a payment schedule. (Id. at 89–108) Plan members are responsible for paying deductibles and all amounts exceeding eligible coverage under the terms of the Plan. (Id. at 43, 76) The Plan covers “80% (of the recognized charge) per visit” for home health services up to a total of 120 maximum visits per calendar year. (Id. at 96) (emphasis in original) “Recognized Charge”3 is a defined term under the Plan. (Id. at 76–77, 115–17) Effective

January 1, 2019, the definition of Recognized Charge was amended under the Plan. (D.I. 19 at

summary judgment. See, e.g., Brewer ex rel. Z.C. v. Berryhill, C.A. No. 17-694-LPS, 2018 WL 4554505, at *1 n.2 (D. Del. Sept. 21, 2018) (construing a pro se plaintiff’s opening brief as a motion for summary judgment in a social security administrative appeal). 2 On June 27, 2020, the parties filed a joint case management report (the “joint report”) pursuant to Fed. R. Civ. P. 26(f). (D.I. 11) In the joint report, the parties agreed to resolve this matter through cross-briefing based on the administrative record. (Id. at 3) Mr. Goldstein argues that he was never provided with a copy of the joint report. (D.I. 15 at 3–4) Despite Mr. Goldstein’s contention that he did not stipulate to the joint report, he has not argued any prejudice, nor has he proffered an alternative case management proposal. (See D.I. 15; D.I. 21) Regardless, the court has considered all of Mr. Goldstein’s filings on the docket in addressing his motion for summary judgment. The briefing for the pending motion is as follows: Mr. Goldstein’s opening brief (D.I. 7), Mr. Goldstein’s reply briefs (D.I. 13; D.I. 21), Mr. Goldstein’s answering brief (D.I. 14), Mr. Goldstein’s status report (D.I. 15), and Defendants’ answering brief (D.I. 18). 3 The court refers to the term “Recognized Charge” throughout this Report and Recommendation as it is defined in the Plan. 115–17) Before the amendment became effective, the Plan defined Recognized Charge as “[t]he reasonable amount rate.” (Id. at 76) For home health care services in particular, the Plan set the reasonable amount rate according to rates for such services in a geographic area as reported by FAIR Health,4 a non-profit company that maintained a database on health care costs. (Id. at 76–

77) As of January 1, 2019, however, the Plan defined Recognized Charge as “[a]n amount determined by Aetna, or its third-party vendors, based on data resources selected by Aetna, reflecting typical competitive charges and/or payments for a service, adjusted for the geographic area in which the service was provided.” (Id. at 115) At all relevant times, under the Plan’s terms, Aetna has discretion to pay all, some, or none of the Recognized Charge of a member’s claim for coverage. (Id. at 47) Aetna also has discretionary authority to review and decide a member’s appeal of an “adverse benefit determination.” (Id. at 47–50) An “adverse benefit determination” occurs “[a]ny time [Aetna] den[ies] even part of the claim.” (Id. at 47) The Plan provides a process for members to appeal any adverse benefit determination. (Id. at 47–50) In most situations, members must undertake

two levels of internal appeals before commencing suit to recover benefits. (Id. at 49)

4 In an attachment to their answering brief, Defendants request that the court take judicial notice of FAIR Health’s website, a screenshot of which is included within the body of their answering brief and is labeled “Exhibit 1.” (See D.I. 18-2; D.I. 18, Ex. 1) Mr. Goldstein argues that Defendants did not provide the court with any “background material” or “information” regarding FAIR Health’s role in resolving the disputes before court. (D.I. 21 at 1–2) The court declines to take judicial notice of what Defendants purport is FAIR Health’s website because, as Mr. Goldstein argues, it has no bearing on the court’s analysis of whether Aetna abused its discretion in handling his claims as of January 1, 2019. B. Factual and Procedural Background 1. Mr. Goldstein’s 2019 Claims In 2019, Mr. and Mrs. Goldstein received home health care services from RRW Inc. d/b/a

Home Instead Senior Care (“Home Instead”). (See, e.g., D.I. 16 at 289, 418–19, 473) Home Instead charged Mr. Goldstein $23 per hour, amounting to $92 for every four-hour session. (Id.) Mr. Goldstein paid Home Instead out-of-pocket in full and then filed claims for reimbursement with Aetna. (D.I. 7 at 4–5; D.I. 18 at 4) Aetna reimbursed Mr. Goldstein’s 2019 claims at a rate of 80% of the Recognized Charge for every four-hour session of home health care by Home Instead. (D.I. 16 at 312, 430, 440, 498) After he was allegedly underpaid on the covered reimbursement amounts, Mr. Goldstein filed multiple first level appeals with Aetna, arguing that the payments were insufficient according to the terms of the Plan. (Id. at 419, 493, 528) Aetna timely responded to Mr. Goldstein’s first level appeals and upheld its decisions to reimburse Mr. Goldstein at a rate of 80% of $65, the Recognized Charge for home health care services. (Id. at

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