Selby v. Principal Mutual Life Insurance

197 F.R.D. 48, 2000 U.S. Dist. LEXIS 13279, 2000 WL 1336279
CourtDistrict Court, S.D. New York
DecidedSeptember 15, 2000
DocketNo. 98CIV.5283(RLC)
StatusPublished
Cited by24 cases

This text of 197 F.R.D. 48 (Selby v. Principal Mutual Life Insurance) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Selby v. Principal Mutual Life Insurance, 197 F.R.D. 48, 2000 U.S. Dist. LEXIS 13279, 2000 WL 1336279 (S.D.N.Y. 2000).

Opinion

OPINION

ROBERT L. CARTER, District Judge.

Plaintiffs Adrian W. Selby and Jill Selby (“the Selbys”) allege that Principal Life Insurance Company f/k/a Principal Mutual Life Insuranee Company (“Principal”) committed various errors when processing their insurance claims for health benefits, and now move pursuant to Rule 23, F.R. Civ. P., to certify three plaintiff classes challenging Principal’s interpretation of its infertility treatment exclusion, and challenging whether Principal’s claims review and appeal procedures satisfy the Employment Retirement Income Security Act (ERISA) provisions governing the administration of health benefit plans.1

I. BACKGROUND

Adrian and Jill Selby are New York residents who were enrolled in a Principal-sponsored health benefit plan; the plan was made available through Adrian Selby’s employer, Carbiner International, Incorporated (the “Carbiner plan”). (Am. Cmplt. at 2).2 The Selbys were enrolled in the Carbiner plan from April, 1993, until the plan expired in July, 1997.3 (Id.) The Carbiner plan provided that insureds’ claims for “Medically Necessary Care” would be fully reimbursed, subject to certain plan exclusions. (Doyle Aff. Ex. 2) (Am. Cmplt. at 3-4). The Carbiner plan also included an “infertility treatment exclusion,” which provided that insureds would not be reimbursed for any medical costs stemming from a “confinement, treatment or service related to the restoration of fertility or the promotion of conception.” (Id. at 4). The Selbys were provided with information detailing these plan provisions; however, this information did not refer to N.Y. Ins. L. § 3221(k)(6)(A) & (B),4 or indi[53]*53cate that the statute might affect Principal’s interpretation of the Carbiner plan’s infertility treatment exclusion. (Id.).5

A. Infertility Treatment Dispute

The Selbys dispute with Principal began in 1996 when Ms. Selby submitted for reimbursement bills associated with treatments she had received to maintain her pregnancies. These treatments were provided by Dr. David Sami. (Am. Cmplt. at 6). Dr. Sami concluded that Ms. Selby was not infertile, because she had conceived on several occasions while under his care; rather her medical problem was that she suffered recurrent miscarriages. (Id.) Therefore, Dr. Sami tailored an individualized course of treatment for Ms. Selby to maintain her pregnancies: testing to determine whether she was pregnant, hormonal treatments, antibiotic drug therapies and intravenous antibiotic treatments (“pregnancy maintenance treatments”). (Id.). Some of these treatments were designed to alleviate Ms. Selby’s cervicitis and her endocrine dysfunction, medical conditions which Dr. Sami believed were causing Ms. Selby to miscarry. (Am. Cmplt. at 7).

Principal ultimately denied Ms. Selby’s claims for the pregnancy maintenance treatments, and sent Ms. Selby several computer generated claim denial letters to explain why her claims had been rejected. (Am. Cmplt. at 6) (referring to these letters as “Explanation of Benefit” letters). These letters, which were sent between March 5, 1997, and September 10, 1997, listed various codes to identify the medical procedures the claims concerned, but failed to explain which plan provisions had caused the claims to be denied. The only explanatory comments in the letters were standard computer generated remarks stating, “[wje’ve excluded the non-covered charges under your plan” and “[yjour plan doesn’t cover confinement, treatment or service related to this condition.” (Am. Cmplt. at 7).

The Selbys appealed Principal’s decision to deny their claims for the pregnancy maintenance treatments. During the course of this appeal, the Selbys received a letter from Principal’s Regional Processing Center, dated May 29, 1997, which stated that the pregnancy maintenance treatments Ms. Selby had received were not reimbursable under the Carbiner plan because all services related to the restoration of fertility or the promotion of conception were disallowed under the plan, unless required by state law,- and New York did not require coverage for such treatment. (Am. Cmplt. at 9). Dr. Sami also sent Principal letters during the course of the appeal. (Doyle Aff. Ex. 17). His letters indicated that Ms. Selby’s pregnancy maintenance treatments were covered under the Carbiner plan as treatments for endocrine dysfunction and cervicitis and, even though the treatments were also linked to pregnancy-related problems, N.Y. Ins. L. § 3221(k)(6)(A) & (B) required that the treatments be covered under the plan. (Am. Cmplt. at 9). Principal however, continued to reject the Selbys’ arguments and refused to pay the costs of the pregnancy maintenance treatments.

B. On-Line Review Dispute

After their dispute with Principal over the pregnancy maintenance treatments, the Selbys reviewed other claims they had submitted to their insurer, and learned that these bills had been automatically denied during a process called “on-line review.” On-line review is the first stage in Principal’s claims review process. During this review, a claim is assigned a diagnosis code based on the illness or condition the insured’s doctor has identified as the reason for the insured’s treatment, and the claim is assigned a procedure code for the service the doctor per[54]*54formed. If a claim lists several diagnoses in connection with a service or procedure, the claims worker only assigns the claim a single diagnosis code based on the first diagnosis the insured’s doctor lists on the claim.6 (Am. Cmplt. at 12) (Crisp. Aff. at 4).7 After the claims worker enters a diagnosis and a procedure code for a claim, she determines if these codes match with the codes always approved for reimbursement under the insured’s health benefit plan. If a match is established, the claims worker marks the claim with a “yes” code, and the claim is automatically paid. (Am. Cmplt. at 12) (Crisp. Aff. at 2). Alternatively, when a claim has been assigned a diagnosis and a procedure code that fall within a plan exclusion, the claim is automatically denied. (Am. Cmplt. at 12) (Crisp. Aff. at 2).

On review of their own records and records from Principal’s files, the Selbys discovered that they had submitted claims for services that Drs. Sage Rainbow, John S. Rodman, and David Sami had performed which all listed multiple diagnoses as a basis for the treatments the doctors provided, and each of these doctors’ claims was altered during on-line" review so that it listed a single diagnosis. (Moore Aff. Ex. 19 & 20) These records also showed that the claims from all three doctors were subsequently denied. (Reply. Mem. at 6) (Moore Aff. Exs. 19 & 20). The Selbys thereafter filed the first amended class complaint currently before the court, challenging Principal’s interpretation of its infertility treatment exclusion, and alleging that Principal’s claims review and claims appeal procedures fail to comport with the ERISA guidelines governing the administration of health benefit plans.

II. DISCUSSION

On review of a motion for class certification under Rule 23, F.R. Civ. P., the court assumes that the allegations raised in the plaintiffs complaint are true, and plaintiff bears the burden of establishing that the class meets the Rule 23 requirements.

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Bluebook (online)
197 F.R.D. 48, 2000 U.S. Dist. LEXIS 13279, 2000 WL 1336279, Counsel Stack Legal Research, https://law.counselstack.com/opinion/selby-v-principal-mutual-life-insurance-nysd-2000.