Zucca v. First Energy Service Company

CourtDistrict Court, N.D. Ohio
DecidedNovember 21, 2022
Docket5:21-cv-01345
StatusUnknown

This text of Zucca v. First Energy Service Company (Zucca v. First Energy Service Company) is published on Counsel Stack Legal Research, covering District Court, N.D. Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Zucca v. First Energy Service Company, (N.D. Ohio 2022).

Opinion

IN THE UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF OHIO EASTERN DIVISON

MARK ZUCCA, ) CASE NO. 5:21-CV-01345-CEH )

) Plaintiff, ) MAGISTRATE JUDGE

) CARMEN E. HENDERSON v. )

) FIRST ENERGY SERVICE CO., et al., ) MEMORANDUM OF OPINION AND ) ORDER Defendant, )

This matter is before the Court on cross motions for judgment on the administrative record under the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§1001-1464 (“ERISA”). The Plaintiff asks this Court to (1) find the services provided by Dr. Elise Roberts (“Dr. Roberts”) should be treated as an in-network provider, (2) issue an Order awarding plaintiff damage for costs previously paid by him directly, and (3) award reasonable attorney’s fees pursuant to 29 U.S.C. §1132(g)(1), and Court costs. (ECF No. 28 at 1) The Defendants ask this Court to (1) enter judgment in Defendants’ favor as there is no genuine issue of fact for trial. (ECF No. 29 at 1). Additionally, Defendant filed a Motion to Strike Exhibits 1 and 2 attached to Plaintiff’s Reply in Further Support of his Motion for Judgment on the Administrative Record. (ECF No. 34 at 1). Having reviewed the cross motions, the First Energy Health Care Plan (“the Plan”), the Administrative Record (“Record”), and relevant caselaw, this Court GRANTS Defendants’ Motion to Strike Exhibits 1 and 2 attached to Plaintiff’s Reply in Further Support of his Motion for Judgment on the Administrative Record (ECF No. 34), DENIES Defendants’ motion for judgment on the administrative record (ECF No. 29), and GRANTS Plaintiff’s cross motion for judgment on the administrative record (ECF No. 28).

I. Background The background facts of this case are not in dispute. Plaintiff, Mark Zucca (“Mr. Zucca”) is an employee who is an eligible participant in the First Energy Healthcare Plan. Mr. Zucca filed a complaint under ERISA, against First Energy Service Company (“FESC”) and Company Insurance Company d/b/a Anthem Blue Cross and Blue Shield (“Anthem”), (collectively, “Defendants”). Mr. Zucca received health benefits through his employer under the Plan, which is

governed by ERISA. (ECF No. 21 at 1431). A. A.Z.’s Medical Diagnoses and Treatment. Mr. Zucca’s son (“A.Z.”) is a nine-year-old boy who was diagnosed with autism spectrum

disorder, mixed receptive language disorder and disruptive behavior in a pediatric patient. Since being diagnosed, A.Z. has been treated by two speech/language pathologists Gina Rowland (“Rowland”) and Ashton Gress (“Gress”). The Record indicates that after treating A.Z. for five- years Rowland determined A.Z.’s needs were “beyond the scope of early intervention and that A.Z. required more than she could provide.” (ECF No. 21 at 75-76.) After treating A.Z. for three- years, Gress concluded A.Z.’s narrative language “has become a huge obstacle” and a safety concern. (ECF No. 21 at 6).

Gress recommended that A.Z. consult with Dr. Roberts, a speech/language pathologist with a doctorate in speech and hearing science, who is certified as a MindWing trainer with

1 All references to page numbers are to the page identification number generated by the Court’s electronic filing system that corresponds to the administrative record page number. extensive training and professional experience in advanced narrative language intervention. (ECF No. 21 at 6.) Dr. Deepa Menon (“Dr. Menon”), A.Z.’s primary physician, explained A.Z.’s medical diagnoses have profoundly impacted A.Z.’s speech and language abilities and that specialized speech therapy in the form of the Story Grammar Marker program is essential. The Story Grammar

Marker program is a type of narrative language intervention that is backed by research. (ECF No. 21 at 224). In March of 2020, A.Z. underwent an assessment with Dr. Roberts, who deemed A.Z. in need of targeted narrative language treatment. In Dr. Robert’s medical opinion: [A.Z.] demonstrates multiple speech[,] language [and] learning issues. He has developed words and sentences but struggles significantly sharing, for example, the events of the day. Despite learning to read, he has made limited gains in narrative development, the highest level of language. Therefore, his stories are limited and lack perspective taking. This interferes with his ability to access the curriculum and participates [sic] in social interactions. He cannot tell events if something has occurred, which may have a positive or adverse effects. This poses significant implications on the potential for [A.Z.]’s independent functioning as, should his safety come into jeopardy, he would not be able to be a valid and reliable reporter. Moreover, [A.Z.] has word finding problems, often unable to come up with or know the word for an object or a way to talk about it. In addition, he struggles understanding and interpreting social cues. Finally, [A.Z.] demonstrates executive function difficulties, which interfere with development of situational awareness, including but not limited to the ability to observe, orient, decide, and act. Given the complexity of [A.Z.]’s speech [and] language needs, he requires a therapist with specializations in areas that are not traditional speech [and] language therapy. He requires support to provide linear order to the chaos of his stories for academic and social interactions. This requires an understanding of narratives and impact of these on social and academic experiences. (ECF No. 21 at 76). Dr. Roberts began treating A.Z. in March of 2020. (ECF No. 21 at 77). B. Mr. Zucca Appeals Anthem’s Decision. Anthem has been designated as the Claims Administrator for the Plan. (ECF No. 21 at 188). Due to the COVID-19 pandemic, Anthem waived member cost-sharing for out of network telehealth services through July of 2020; thus, the services Dr. Roberts provided from March of 2020 to July of 2020, were covered at the in-network benefit rate. Realizing the cost-sharing waiver

would end, Mr. Zucca attempted to obtain authorization to continue A.Z.’s treatment with Dr. Roberts on an “in for out” basis. (ECF No. 21 at 2-3, 25). According to the language of the Plan, an “in for out” basis refers to “where there is no network Provider available for the Covered Services, the Plan may authorize the network cost share amounts (deductible and/or coinsurance) to apply to a claim for a Covered Service you may receive from an out-of-network Provider.” (ECF No. 21 at 15).

On November 9, 2020, Anthem denied the request in a letter to Mr. Zucca on the basis that Mr. Zucca did not contact Anthem prior to receiving the services of Dr. Roberts. (ECF No. 21 at 19). On November 20, 2020, Mr. Zucca followed up with Anthem. (ECF No. 21 at 24). Dr. Roberts also requested to be considered as “in-network”. (ECF No. 21 at 30). On December 14, 2020, Anthem again responded to Mr. Zucca, noting it was retaining its original decision, because “[t]here are in-network doctors that can provide this service.” (ECF No. 21).

The Plan sets forth a multi-step appeal process. (ECF No. 28 at 6) Upon receipt of an adverse benefit determination, the claimant may file an appeal (“Level One Appeal”), after which the Plan Administrator or its designee [in this case Anthem] will make a decision. On January 4, 2021, Mr. Zucca initiated a Level One Appeal. The documentation Mr. Zucca submitted in support of the appeal established, “[e]ach of the providers in our area who participate with Anthem have agreed their services are no longer a best match for A.Z.’s needs”. (ECF No. 21 at 35). On January 11, 2021, Mr. Zucca provided Anthem with Dr. Roberts’ report and notes. (ECF No. 21 at 73-80, 355). On January 28, 2021, Anthem denied Mr.

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