Klebe v. Mitre Group Health Care Plan

894 F. Supp. 898, 19 Employee Benefits Cas. (BNA) 1756, 1995 U.S. Dist. LEXIS 11910, 1995 WL 493106
CourtDistrict Court, D. Maryland
DecidedAugust 17, 1995
DocketCiv. PJM 92-3130
StatusPublished
Cited by9 cases

This text of 894 F. Supp. 898 (Klebe v. Mitre Group Health Care Plan) is published on Counsel Stack Legal Research, covering District Court, D. Maryland primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Klebe v. Mitre Group Health Care Plan, 894 F. Supp. 898, 19 Employee Benefits Cas. (BNA) 1756, 1995 U.S. Dist. LEXIS 11910, 1995 WL 493106 (D. Md. 1995).

Opinion

OPINION

MESSITTE, District Judge.

Paul E. and Carol J. Klebe, both employed by MITRE Corporation, bring tMs ERISA action on behalf of their son John, challenging a demal of benefits under MITRE’s self-insured Group Health Plan (the Plan). See 29 U.S.C. § 1132(a)(1)(B). The benefits in *900 question pertain to care provided John at Chestnut Lodge Hospital, a private psychiatric hospital in Rockville, Maryland. MITRE contends that John, who has been diagnosed as a chronic paranoid schizophrenic, has reached his $500,000 lifetime mental health treatment maximum under the Plan. The Klebes argue that schizophrenia is a medical condition and that treatment for John’s condition should be covered under the Plan’s $1,000,000 lifetime medical treatment maximum. Both sides have moved for summary judgment. 1 For the following reasons, the Court grants the Motion of Defendant MITRE and denies those of Plaintiffs.

I.

At age five, John Klebe was diagnosed with polycystic kidney disease. The condition required multiple surgeries including, when John was twelve, the removal of a kidney and the construction of an ileoconduit with ureterostomy. When he was in second grade, John began seeing a psychiatrist, a Dr. Briscoe, whom he continued to consult throughout his youth. John worried about being separated from his parents and had trouble dealing with what he considered to be humiliating kidney problems including improper drainage from his remaining kidney and incontinence. Although he adjusted somewhat to junior high school, by ninth grade John reported that his peers picked on him because he was much smaller than they were. When John began high school, he seemed to adjust to his new surroundings until a car killed his cat, after which he refused to attend school. Dr. Briscoe worked with John regarding his fear of attending school and John gradually returned, but in the first week of his junior year he suffered another setback, developing a hydrocele on his testicle which required surgery. After the surgery John again refused to attend school.

John’s first psychiatric hospitalization, at the Psychiatric Institute of the District of Columbia, occurred in August 1986, following his aborted junior year. The hospitalization was brought on by John’s marked depression and increasingly erratic behavior. At the Psychiatric Institute, John was treated with anti-psychotic and anti-depressant medications and his psychosis abated. After two months, however, John was transferred to the Cumberland Hospital in New Kent, Virginia, for treatment of his residual personality disorder and management of his medical condition involving the ureteral diversion with the ileoconduit. Unable to receive extensive psychotherapy at Cumberland, John was transferred to Chestnut Lodge at the end of January, 1987, upon recommendation of Dr. Briscoe. In December, 1989, John’s parents were informed that his diagnosis was “schizophrenia, paranoid type, chronic.”

Over the years John received various medications in connection with his schizophrenia including Trilafon, Symmetral, Ativan, Retin A, Cleosin, and Tylenol. Throughout, John also participated in intensive psychotherapy, group therapy, milieu therapy, and family therapy. Additionally, towards the end of his stay at Chestnut Lodge, John and his therapist took drives together in the community, ate lunch together once a week in the cafeteria, and engaged in occasional physical activities, including walks and tossing a softball. During this period, John held a volunteer and eventually a paid position at the local library. He also worked in the hospital’s dietary and cash offices. His therapist observed that “(John) should be able to achieve gainful employment on a part-time basis,” but cautioned “that John will need ongoing supervised living situations as well as ongoing therapy for his chronic schizophrenia over several years. His medical condition will also need to be monitored throughout his lifetime.”

At the time this suit was filed, John was 24 years old.

II.

The Plan provides coverage to its participants under two separate lifetime benefit máximums as follows:

*901 Lifetime Maximum Benefits
In addition to máximums for certain types of benefits specified elsewhere in this description of the [Plan], there is a lifetime medical maximum of $1,000,000 per person for both the high and low option plans. There is a separate lifetime mental health benefit maximum of $500,000 per plan for the high option and $100,000 for the low option plan____
Mental Health Treatment
The [Plan] provides the same level of benefits for inpatient mental health treatment as for other illnesses.... however, the lifetime maximum benefit per covered individual for all mental health, substance abuse and drug dependency treatment, inpatient and outpatient, is $500,000 for the high option plan____

The “Mental Health” section of the Plan includes provisions for the treatment of “mental, psychoneurotic, or personality disorder.” Within the “Mental Health” section, “consulting, diagnostic, and treatment sessions by a licensed____psychologist, or psychiatrist” are covered under “Outpatient Mental Health Treatment.”

Paul Klebe carries the High Option Plan, which also covers John. 2

According to Carolyn Brownawell, MITRE’s Director of Corporate Compensation and Benefits, past practice under the Plan has been to charge expenses for intensive psychotherapy, individual therapy, group therapy, family therapy and milieu therapy against a beneficiary’s mental health lifetime maximum regardless of the nature or cause of the illness. This has been true not only with respect to John Klebe, but for all other plan participants. Carol Klebe, moreover, concedes that she directed Chestnut Lodge to file separate claims for John, one for all his psychological related charges and another for medications related to his kidney condition. She did this, she says, because of the division between “MITRE’s medical and psychiatric” categories.

In May 1992, having been notified by the Plan that John’s $500,000 mental health maximum had been reached, the Klebes sought to have his diagnosed condition of “paranoid schizophrenia” covered under the $1,000,000 lifetime medical benefit maximum instead of the $500,000 lifetime mental health benefit maximum. They argued that, since John’s condition was biological in nature, it required at least some medical treatment and was therefore assignable to that category of coverage.

When the Klebe’s ERISA review resulted in an unfavorable decision, this litigation followed.

III.

Rule 56 of the Federal Rules of Civil Procedure provides that a motion for summary judgment must be granted if there is no genuine issue of material fact and the moving party is entitled to judgment as a matter of law.

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Cite This Page — Counsel Stack

Bluebook (online)
894 F. Supp. 898, 19 Employee Benefits Cas. (BNA) 1756, 1995 U.S. Dist. LEXIS 11910, 1995 WL 493106, Counsel Stack Legal Research, https://law.counselstack.com/opinion/klebe-v-mitre-group-health-care-plan-mdd-1995.