Jacqueline A. v. Mpihp

• Court: Court of Appeals for the Ninth Circuit
• Decided: November 21, 2019
• Docket: 18-56187
• Status: Unpublished

Opinion

NOT FOR PUBLICATION FILED UNITED STATES COURT OF APPEALS NOV 21 2019 MOLLY C. DWYER, CLERK U.S. COURT OF APPEALS FOR THE NINTH CIRCUIT

JACQUELINE A., No. 18-56187

Plaintiff-Appellant, D.C. No. 2:17-cv-04333-JAK-JEM v.

MOTION PICTURE INDUSTRY HEALTH MEMORANDUM* PLAN; OPTUMHEALTH BEHAVIORAL SOLUTIONS OF CALIFORNIA, INC.,

Defendants-Appellees.

Appeal from the United States District Court for the Central District of California John A. Kronstadt, District Judge, Presiding

Argued and Submitted November 7, 2019 Pasadena, California

Before: MURGUIA and HURWITZ, Circuit Judges, and ZOUHARY, ** District Judge.

After being denied coverage for several mental health treatment claims,

Jacqueline A. brought this action against the Motion Picture Industry Health Plan

* This disposition is not appropriate for publication and is not precedent except as provided by Ninth Circuit Rule 36-3. ** The Honorable Jack Zouhary, United States District Judge for the Northern District of Ohio, sitting by designation. (the “Plan”), a plan governed by the Employee Retirement Income Security Act, and

OptumHealth Behavioral Solutions of California, Inc., the Plan claims administrator.

The district court held a bench trial and entered judgment in favor of the Plan and

Optum.1

1. The district court correctly reviewed the Plan’s decisions for abuse of

discretion. The Plan documents provided the Plan’s directors with full discretion to

make eligibility determinations, and the authority to make final and binding

interpretations of plan provisions. See Abatie v. Alta Health & Life Ins. Co., 458

F.3d 955, 963 (9th Cir. 2006) (en banc) (“[W]e have repeatedly held that similar

plan wording—granting the power to interpret plan terms and to make final benefits

determinations—confers discretion on the plan administrator.”). Because the Plan

allowed the directors to delegate benefits administration, and that power was

formally delegated to Optum, the administrator’s determinations are also subject to

abuse of discretion review. See Madden v. ITT Long Term Disability Plan for

Salaried Emps., 914 F.2d 1279, 1283–85 (9th Cir. 1990).

2. We review for abuse of discretion despite Optum’s untimely decision

on two of Jacqueline’s initial appeals. The district court remanded the two appeals

1 Optum, as a plan administrator, was properly named as a defendant. The denials for each request for benefits at issue in this case came from Optum. See Spinedex Physical Therapy USA Inc. v. United Healthcare of Ariz., Inc., 770 F.3d 1282, 1297 (9th Cir. 2014) (holding that an ERISA plan administrator can be liable if it “cause[s] improper denial of benefits”) (citing 29 U.S.C. § 1132(a)(1)(B)).

2 to Optum for a decision on the merits. On remand, Optum considered supplemental

materials submitted by Jacqueline, and exercised its discretion in deciding the

appeals on the merits. See LaMantia v. Voluntary Plan Adm’rs, Inc., 401 F.3d 1114,

1123–24 (9th Cir. 2005).

3. The denials of coverage were not an abuse of discretion. The reasons

provided by Optum’s reviewing physicians were not “illogical” and were “drawn

from the facts in the record.” Salomaa v. Honda Long Term Disability Plan, 642

F.3d 666, 676 (9th Cir. 2011) (quoting United States v. Hinkson, 585 F.3d 1247,

1262 (9th Cir. 2009) (en banc)). And, Optum always authorized treatment, albeit at

a less intensive level of care than Jacqueline sought. See Stephan v. Unum Life Ins.

Co. of Am., 697 F.3d 917, 929 (9th Cir. 2012) (“Under this deferential standard, a

plan administrator’s decision ‘will not be disturbed if reasonable.’”) (quoting

Conkright v. Frommert, 559 U.S. 506, 521 (2010)).

AFFIRMED.