Wesson v. Jane Phillips Medical Center & Affiliates Employee Group Healthcare Plan, Premium Plan

870 F. Supp. 2d 1263, 2012 U.S. Dist. LEXIS 59569, 2012 WL 1536458
District Court, N.D. Oklahoma·Decided April 30, 2012·No. Case No. 09-CV-561-JHP-FHM·Published·Cited by 2 cases

Opinion

OPINION & ORDER

JAMES H. PAYNE, District Judge.

Before the Court in ERISA1 is Plaintiffs Opening Brief on the Merits, Plain[1266]*1266tiffs Response Brief, and Plaintiffs Reply Brief;2 and the Opening Brief of Defendants Jane Phillips Medical Center and Jane Phillips and Affiliates Employee Group Health Care Plan, the Response Brief of Defendants Jane Phillips Medical Center and Jane Phillips and Affiliates Employee Group Health Care Plan, and the Reply Brief by Defendants Jane Phillips Medical Center and Jane Phillips and Affiliates Employee Group Health Care Plan.3 For the reasons cited herein, Defendant JPMC’s final determination denying medical benefits is AFFIRMED. Plaintiffs claim for Breach of Fiduciary Duty is DENIED.

BACKGROUND

A. Policy Coverage and Provisions

Throughout 2005 and 2008, the relevant years in this case, Plaintiff was an employee of Defendant Jane Phillips Medical Center (“JPMC”) and was a participant in JPMC’s group health plan (“Plan”).4 The Plan is a self-funded employee health plan with funds coming from both employee contributions and employer contributions made by Defendant JPMC.5 In April 2005, Plaintiff underwent a Roux-en-Y gastric bypass weight loss surgery to treat obesity.6 The 2005 bypass surgery was covered by the Plan and benefits were paid to the extent of the Plan’s maximum lifetime treatment coverage of $15,000 for morbid obesity.7 The relevant Plan language regarding maximum lifetime treatment coverage reads:

Morbid Obesity — The Plan covers obesity treatment if such treatment is deemed Medically Necessary and diagnosed as a condition in which an individual is obese as defined by the National Heart, Lung, and Blood Institute, and its guidelines of 1998 if the following criteria is met: (1) A body mass index of 40 or over 35 if the patient has other existing co-morbid diagnosis (as determined by the Body Mass Index table). (2) The patient is evaluated by a surgeon, psychiatrist and nutritionist. (3) The patient selects a surgeon with experience in gastric bypass surgery procedures. (4) A plan of treatment is submitted by the surgeon to case management for review. Treatment of complications (to include other organs), as a result of obesity services(s) will not be covered by this Plan. See your Plan Supervisor for a copy of the institute’s guidelines as well as the Medical Exclusions and Limitations in this booklet for more information.

Payment under this benefit will be limited to: Lifetime Maximum of $15,000.8

In 2008 Plaintiff experienced health problems, such as depression, lack of appetite, acid reflux, inability to keep solid foods down, and weight loss.9 Plaintiff sought treatment for these symptoms from her doctors and ultimately underwent two dilation procedures and a surgery to repair an area of gastric stricture.10 The operative note from the July 2008 surgery states that the operation performed was a [1267]*1267“[tjakedown of the gastrojejunostomy with reconstruction.”11

B. Administrative Adjudication of Plaintiff’s Claim.

Plaintiff sought coverage for these 2008 doctor visits and medical procedures by submitting health insurance claims to the Plan.12 Plaintiffs initial claim was denied by Plan Supervisor BMI HealthPlans, Inc. (BMI).13 Plaintiff sought review of the initial decision, with Plan supervisor BMI receiving the request for review on September 15, 2008.14 Plaintiffs request for review included no supporting supplemental information.15

On October 8, 2008 BMI issued its decision, confirming the denial of Plaintiffs claim, citing that Plaintiffs claim exceeded the Plan’s $15,000 lifetime limit for medical services connected with morbid obesity based on its determination that the 2008 procedures resulted from a complication of the original 2005 gastric bypass.16 The denial letter advised Plaintiff of her right to appeal the decision to the Plan Administrator and the procedure for pursuing that appeal.17 The letter specifically stated that Plaintiff must submit any supplemental material supporting her claim along with her notice of appeal.18

On January 9, 2009, Plaintiff initiated an appeal to Plan administrator JPMC.19 Plaintiff disagreed with BMI’s determination that the 2008 procedures resulted from a complication of the original 2005 gastric bypass, arguing instead that the gastric obstruction was caused by stress and the resulting chronic acid reflux.20 With her notice of appeal, Plaintiff submitted multiple articles supporting her contention.21

Defendant JPMC gathered all of Plaintiffs appeal materials and the medical records related to the 2008 surgeries and submitted them to HealthReview, L.L.C., an independent medical review company.22 Notably absent from the records was any record of the 2005 procedure. A registered nurse from HealthReview, L.L.C. reviewed the materials submitted by JPMC and concluded that Plaintiffs 2008 surgeries were the result of complications arising from the 2005 procedure.23

Defendant JPMC then submitted the materials to AUMed Healthcare Management (AllMed) for further independent medical review.24 The independent review, by Dr. Skip Freedman, stated that he reviewed all submitted material and concluded that “[tjhis surgery was done for a condition that was a result of the prior gastric bypass procedure.”25 Lacking any records from Plaintiffs 2005 procedure, Dr. Freedman’s report assumed that Plaintiffs 2005 surgery was a vertical banded gastroplasty, rather than the Roux-en-Y gastric bypass Plaintiff actually received.26 Based on Dr. Freedman’s [1268]*1268report, Defendant JPMC affirmed the denial of Plaintiffs claim.27 On August 31, 2009, having exhausted all administrative remedies, Plaintiff filed her claim in this court.28

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

Wesson v. Jane Phillips Medical Center & Affiliates Employee Group Healthcare Plan, Premium Plan, 870 F. Supp. 2d 1263, 2012 U.S. Dist. LEXIS 59569, 2012 WL 1536458 (N.D. Okla. 2012).

870 F. Supp. 2d 1263 (Wesson v. Jane Phillips Medical Center & Affiliates Employee Group Healthcare Plan, Premium Plan) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

Related

Blair v. Metropolitan Life Insurance
955 F. Supp. 2d 1229 (N.D. Alabama, 2013)