Utah Alcoholism Foundation v. Battelle Pacific Northwest Laboratories-Non-Bargaining Unit Employees' Comprehensive Medical Benefits Plan

204 F. Supp. 2d 1295, 28 Employee Benefits Cas. (BNA) 1547, 2002 U.S. Dist. LEXIS 11188, 2002 WL 1358664
CourtDistrict Court, D. Utah
DecidedJune 17, 2002
DocketNo. 2:98-CV-648 RNB
StatusPublished
Cited by1 cases

This text of 204 F. Supp. 2d 1295 (Utah Alcoholism Foundation v. Battelle Pacific Northwest Laboratories-Non-Bargaining Unit Employees' Comprehensive Medical Benefits Plan) 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
Utah Alcoholism Foundation v. Battelle Pacific Northwest Laboratories-Non-Bargaining Unit Employees' Comprehensive Medical Benefits Plan, 204 F. Supp. 2d 1295, 28 Employee Benefits Cas. (BNA) 1547, 2002 U.S. Dist. LEXIS 11188, 2002 WL 1358664 (D. Utah 2002).

Opinion

MEMORANDUM & ORDER

BOYCE, United States Magistrate Judge.

Plaintiffs filed suit under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001-1461, to recover benefits allegedly due them, pursuant to 29 U.S.C. § 1132(a)(1)(B), and for statutory penalties, pursuant to 29 U.S.C. § 1132(c)(1). The parties agreed to have the magistrate judge conduct all proceedings in this case pursuant to 28 U.S.C. § 636(c)(1).. (File entries 107 & 108.) The case is presently before the court on the parties’ cross-motions for summary judgment.

I. FACTUAL BACKGROUND2

Plaintiffs Ryan Powell and Jesse Powell were beneficiaries of the Battelle Pacific Northwest Laboratories-Non-Bargaining Unit Employees’ Comprehensive Medical Benefits Plan (“the Plan”) through the employment of their stepfather, John Fallon, III, with Battelle Pacific Northwest Laboratories (“Battelle”) in the State of Washington. The Plan is an employee welfare benefit plan as defined by ERISA. During the relevant time period, defendant Roger K. Ballard was the Plan Administrator.

Plaintiffs Jesse and Ryan Powell received in-patient treatment at Brightway Adolescent Hospital in St. George, Utah from September 9, 1995 through September 25, 1995 for mental, emotional, behavioral, and substance abuse problems. (See Admin. R. at B00449-B00534.)3 In January and February 1996, claims for benefits for the boys’ treatment were submitted to the Plan through its third-party claims administrator, the Travelers Plan Administrators (“the TPA”). In April 1996, the TPA sent an Explanation of Benefits (EOB) for each boy denying benefits on the ground that the “inpatient stay was not medically necessary.” (Ex. 3 to defs.’ Mem. Supp. Mot. Summ. J, file entry 64.)

Subsequently, Brightway contracted with Claims Management, Inc. (“CMI”), a Utah corporation, to provide auditing services and to pursue unpaid claims for benefits. On January 15, 1998, John Fallon, III, signed a form authorizing CMI to act on his behalf with regard to the claims and to obtain copies of relevant plan documents. (See Authorization for Claims Management Inc. to Obtain and Release Information Concerning Patient, attached to letter dated January, 19, 1998, ex. A to orig. compl., file entry 1.)

On January 19, 1998, CMI wrote Bat-telle a letter directed to the attention- of the Plan Administrator requesting the Summary Plan Description (SPD) and the Plan Document that were in effect in 1995.4 (Letter, ex. A to original compl.) On February 10, 1998, having received no response to its earlier request, CMI faxed a copy of the January 19,1998 letter, along with the authorization from Mr. Fallon, to Judy Holly, the benefits coordinator, at [1298]*1298Battelle. (Fax cover sheet, ex. B to' orig. compl.)5 On February 17, 1998, CMI received a document entitled “Comprehensive Medical Plan, Summary Plan Description.” (See CMI dep. at 29-32, attached as ex. 2 to defs.’ Mem. Supp. Mot. Summ. J, file entry 64.) Plaintiffs assert that this document was only a partial copy of the SPD and that they received no copy of the Plan Document.

On April 6, 1998, CMI wrote two letters to the TPA (one for Ryan Powell and one for Jesse Powell). In these letters, CMI argued that inpatient care for the boys was medically necessary and asked that the Plan “complete a full, fair, and thorough review of this matter.” (Letters, ex. C & D to orig. compl.) The letters also requested, in the event that the denial was maintained, that the TPA provide specific, detailed reasons for the denial, the clinical criteria that was used in determining medical necessity, copies of physician reviewers’ medical opinions and rationale, and the names and credentials of the reviewers who determined the inpatient treatment was not medically necessary. (Letters, ex. C & D to orig. compl.)

On May 19, 1998, the TPA responded to CMI’s letter regarding Ryan. After providing a definition of the term “Medically Necessary,” the TPA stated-as follows:

The medical documentation furnished for the services associated with Ryan Powell’s confinement from September 9, 1995 through September 25, 1995 at Brightway Adolescent Hospital was forwarded to our Medical Review Board for a peer review to be conducted by a board certified physician of the same specialty. The decision made by the physician who performed the peer review is that the documentation does not support the medical necessity for either a psychiatric inpatient level of care nor for a location of care, so far removed from either parent’s home.
Based on the terms of the Battelle Memorial Institute’s Plan Document and the decision of the peer review, no benefits are payable for expenses related to Ryan Powell’s confinement in Brightway Adolescent Hospital from September 9, 1995 through September 25,1995.

(Letter, ex. E to orig. compl.) On June 15, 1998, the TPA sent a similar letter denying the appeal of Jesse Powell. (Letter, ex. . F to orig. compl.)

On May 29, 1998, CMI wrote the TPA indicating that it had received the TPA’s letter concerning Ryan Powell. CMI again requested copies of the written opinions of physician reviewers and their rationale, the names and credentials of the reviewers, an entire copy of the Plan Document and/or the Summary Plan Description, and a copy of the Administrative Services Agreement. (Letter, ex. G to orig. compl.)

On June 9, 1998, CMI wrote a letter to Battelle directed to the attention of the Plan Administrator requesting copies of the plan documents. CMI acknowledged that it had received fourteen pages, but had not received the complete plan document. (Letter, ex. H to orig. compl.)

On July 9, 1998, after receiving the TPA’s June 15, 1998 letter denying Jesse’s appeal, CMI wrote the TPA again requesting the medical reviewers’ credentials, written opinions and rationale, and the clinical criteria used in denying the claim. (Letter, ex. I to orig. compl.)

On July 22, 1998, the TPA responded to CMI by requesting a copy of its business license, any documents showing its associa[1299]*1299tion with the Utah and Oregon insurance departments, and an explanation of which parties it was representing along with copies of any agreements with such parties including signed authorizations to release information to CMI. (Letter, ex. J to orig. compl.) On August 6, 1998, CMI sent the TPA the requested information. (Letter, ex. K to orig. compl.)

On September 8,1998, plaintiffs filed the instant lawsuit. On September 29, 1998, the defendants were served with a copy of the complaint. (See return of service, file entry 2.)

On October 15, 1998, Battelle produced complete copies of the Plan Document and the SPD to CMI.

On November 20, 1998, Roger K. Ballard, the Plan Administrator, wrote to Mr. Fallon to inform him that the appeals were denied as untimely filed. (Letter, Admin. R. at B00S97.) Mr.

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Related

Utah Alcoholism Found. v. BATTELLE PAC. NW LABS.
204 F. Supp. 2d 1295 (D. Utah, 2002)

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204 F. Supp. 2d 1295, 28 Employee Benefits Cas. (BNA) 1547, 2002 U.S. Dist. LEXIS 11188, 2002 WL 1358664, Counsel Stack Legal Research, https://law.counselstack.com/opinion/utah-alcoholism-foundation-v-battelle-pacific-northwest-utd-2002.