Madeline D. v. Anthem Health Plans of Ky., Inc.

369 F. Supp. 3d 1159
CourtDistrict Court, D. Utah
DecidedFebruary 13, 2019
DocketCase No. 2:17-cv-675
StatusPublished
Cited by52 cases

This text of 369 F. Supp. 3d 1159 (Madeline D. v. Anthem Health Plans of Ky., Inc.) is published on Counsel Stack Legal Research, covering District Court, D. Utah primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Madeline D. v. Anthem Health Plans of Ky., Inc., 369 F. Supp. 3d 1159 (D. Utah 2019).

Opinion

Jill N. Parrish, United States District Judge

This ERISA case is before the court on the parties' cross-motions for summary *1166judgment. Defendant Anthem Health Plans of Kentucky, Inc. ("Anthem") moved for summary judgment on June 5, 2018 (ECF No. 38). On June 9, 2018, plaintiffs Michael D. ("Mike") and Madeline D. ("Maddie") (collectively "Plaintiffs") moved for summary judgment as well (ECF No. 40).

I. BACKGROUND

This dispute involves the denial of benefits allegedly due under a group health benefit plan provided by US World Meds, LLC to its employees ("the Plan"). The Plan is fully insured by Anthem and governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1001, et. seq. ("ERISA"). Anthem is also the administrator of the Plan and has reserved discretionary authority to make decisions regarding coverage. Mike, as an employee of US World Meds, LLC, is a participant in the Plan and his daughter Maddie is a beneficiary of the Plan.

A. MADDIE'S HISTORY

Maddie, a very bright girl, has struggled with a variety of mental health conditions over the years, including attention deficit/hyperactivity disorder ("ADHD"), Persistent Depressive Disorder, Borderline and Narcissistic Personality Features, anxiety, suicidal thoughts, and self-harm behavior ("cutting"). On August 30, 2014, Maddie was admitted at Aspiro Wilderness Adventure Therapy ("Aspiro") for stabilization and assessment. She resided there and received "wilderness therapy"1 until she was discharged on November 11, 2014. Maddie was then admitted to Uinta Academy ("Uinta") on November 11, 2014, where she received "residential treatment" for over a year until her discharge on December 17, 2015. Plaintiffs first submitted claims for coverage of the Aspiro medical expenses on April 29, 2015 and for the Uinta expenses on October 26, 2015. Anthem denied both claims.

B. ASPIRO TREATMENT

Upon receipt of Plaintiffs' claims for coverage of treatment at Aspiro, Anthem conducted a retrospective review and denied coverage. The "Explanation of Payment" section of the Explanation of Benefits ("EOBs") sent to Mike from Anthem explains that Anthem reduced payment for the "benefits for this service [at Aspiro] because you were not precertified" and "[p]re-certification is needed for certain services under the Health Care Management guidelines." Then, in a letter dated May 4, 2015, Anthem notified Plaintiffs that Maddie's claim for benefits at Aspiro was denied because there are no benefits in the Plan for a "Wilderness Camp Program." Anthem's letter did not address the precertification issue, nor did it refer Mike to any specific section in his benefit plan.

Mike appealed the denial of the Aspiro claims on October 1, 2015. Anthem received the appeal on October 5, 2015. Mike alleges that he did not receive a response to his appeal for coverage of the Aspiro treatment during the time prescribed by the Plan or by ERISA. Accordingly, on June 24, 2016, Mike wrote a letter to the Kentucky Department of Insurance ("KDOI") asking the Consumer Protection Division to investigate. KDOI contacted Anthem and asked for further information regarding the claims. KDOI and Anthem exchanged various communications. In one response, Anthem provided a copy of the letter it allegedly sent to Mike on November *11674, 2015, denying his appeal for coverage of the "Wilderness Camp Program at Aspiro" because wilderness camps are not a covered benefit. The letter directed Mike to a specific section of his Plan benefits booklet and the EOBs, and informed Mike that he had exhausted his appeal rights with Anthem. On November 16, 2016, KDOI informed Mike that it was upholding Anthem's denial of benefits because Aspiro was a wilderness camp and therefore clearly excluded under the Plan.

C. UINTA TREATMENT

Anthem also denied coverage of treatment at Uinta. EOBs issued to Mike from April 27, 2015 through May 20, 2016 explain payments were not made to cover the services at Uinta because the services were not "pre-certified." Then, in a letter dated November 10, 2015, Anthem informed Mike that, after a retrospective review, Anthem denied coverage for the Uinta expenses because Maddie's treatment at Uinta, a "Residential Treatment Center," was not medically necessary. Mike appealed the denial of the Uinta treatment on May 5, 2016. Anthem notified Mike through letter on June 1, 2016 that it was upholding its decision and that he had exhausted his appeal rights. Mike then requested external review of this decision by an independent review organization on September 26, 2016. The external reviewer upheld Anthem's denial.

Mike and Maddie filed their single-count Complaint on June 23, 2017 seeking recovery of benefits under 29 U.S.C § 1132(a)(1)(B). Under Count One, Plaintiffs also allege that Anthem breached its fiduciary duties under 29 U.S.C. § 1104 and § 1133 by failing to act solely in the interest of the Plan participants and beneficiaries when it denied Maddie's benefits and by failing to provide a full and fair review as required under the Plan and by ERISA. Plaintiffs seek judgment in the amount of $ 200,000.00, plus prejudgment interest pursuant to Utah Code Ann. § 15-1-1, and attorney fees and costs incurred under 29 U.S.C. § 1132(g). The court held oral argument on these motions on January 24, 2019. On the basis of that hearing, the parties' briefs, and a review of the relevant law, the court grants in part and denies in part Anthem's Motion for Summary Judgment and grants in part and denies in part Plaintiffs' Motion for Summary Judgment.

II. LEGAL STANDARD

A. SUMMARY JUDGMENT STANDARD

Under Federal Rule of Civil Procedure 56(a), "[t]he court shall grant summary judgment if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." When both parties move for summary judgment in an ERISA case, thereby stipulating that a trial is unnecessary, "summary judgment is merely a vehicle for deciding the case; the factual determination of eligibility of benefits is decided solely on the administrative record, and the non-moving party is not entitled to the usual inferences in its favor." LaAsmar v. Phelps Dodge Corp. Life, Accidental Death & Dismemberment & Dependent Life Ins. Plan

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

Related

P.E.L. v. Premera Blue Cross
540 P.3d 105 (Washington Supreme Court, 2023)
W. v. Health Net Life Insurance Company
86 F.4th 1265 (Tenth Circuit, 2023)
P.e.l., P.l & J.l., V. Premera Blue Cross
Court of Appeals of Washington, 2022

Cite This Page — Counsel Stack

Bluebook (online)
369 F. Supp. 3d 1159, Counsel Stack Legal Research, https://law.counselstack.com/opinion/madeline-d-v-anthem-health-plans-of-ky-inc-utd-2019.