Beruflich Dokumente
Kultur Dokumente
No. 16-1997
Plaintiff, Appellant,
v.
Defendant, Appellee.
Before
Hon. David H. Souter, Associate Justice (Ret.) of the Supreme
Court of the United States, sitting by designation.
SELYA, Circuit Judge. In this case, brought pursuant to
claim that are now in dispute. The district court, reviewing the
I. BACKGROUND
of Mass. HMO Blue, Inc. (Stephanie I), 813 F.3d 420 (1st Cir.
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problems). Such benefits do not accrue for residential,
custodial, or medically unnecessary services, such as
those performed in "educational, vocational, or
recreational settings." The Certificate also stipulates
that only the least intensive type of setting required
for treatment of a condition will receive approval. Any
non-emergency inpatient course of treatment needs
approval before the patient is admitted to the facility.
. . . .
M.G. experienced a number of mental health issues
beginning in early childhood. . . .
M.G.'s condition intensified in severity in the
summer of 2010 (the summer between his freshman and
sophomore years in high school). At that time, he became
physically aggressive toward his parents and attended
weekly mental health therapy sessions. Although
enrolled in an intensive outpatient educational
facility, he continued to exhibit aggressive behavior
that led to multiple arrests. His problems escalated
because he steadfastly refused to take medications
despite a court order requiring him to do so.
Concerned about the apparent inadequacy of his
care, Stephanie enrolled M.G. (at her own expense and
without prior approval) in Vantage Point by Aspiro
(Aspiro), a wilderness therapy program based in Utah,
which specializes in neurodevelopmental disorders. M.G.
remained at Aspiro from October of 2010 to January of
2011. His psychological evaluators there diagnosed him
as having Asperger's Syndrome, anxiety disorder, and
attention deficit and hyperactivity disorder. Noticing
some improvement, they recommended that he continue
therapy in a longer-term setting.
On the advice of a consultant and without prior
approval, Stephanie proceeded to enroll M.G. in Gateway
Academy (Gateway), a private school treatment center in
Utah that BCBS insists is "out of network" (that is, not
in a contractual relationship with BCBS). While at
Gateway, M.G.'s aggressive and emotionally erratic
behavior continued; among other things, he engaged in
inappropriate sexual contact and committed a variety of
petty criminal offenses.
In April of 2011, Harmonix submitted claims to BCBS
for three sets of psychiatric evaluations and
consultation services (performed during the period from
January 27, 2011 to February 23, 2011) in connection
with M.G.'s admission to Gateway. In late June, BCBS
informed Harmonix that Gateway was a non-covered
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provider but that it would cover the three sets of
evaluations "as a one-time exception." Gateway itself
submitted claims in September of 2011 and March of 2012
seeking reimbursement for principally residential
services rendered to M.G. dating back to January of 2011.
In an informal process, BCBS denied these room and
board claims because the services were not medically
necessary and the submitted documentation did not
support the need for an inpatient admission. In an
explanatory letter dated May 25, 2012, BCBS advised
M.G.'s father that its denial of benefits was based
largely upon an evaluation conducted by Dr. Elyce
Kearns, a psychiatrist-reviewer, who relied upon
"InterQual," a nationally recognized set of criteria
used to assess the level of care for mental health
patients. Given Dr. Kearns' evaluation, BCBS concluded
that M.G.'s "clinical condition does not meet the
medical necessity criteria required for an acute
residential psychiatric stay."
About a year later, Stephanie requested and
received a sheaf of pertinent records from BCBS. She
then contested the denial of coverage through BCBS's
internal review process. In support of her appeal,
Stephanie furnished documentation from M.G.'s
psychotherapists, evaluators, and educators in addition
to police reports and juvenile court records.
Collectively, these materials described M.G.'s
difficulties involving physical and verbal aggression,
emotional volatility, lack of impulse control, and
thinking errors. This pattern of conduct, Stephanie
maintained, posed a danger to M.G. and to others.
A second psychiatrist-reviewer, Dr. Kerim Munir,
scrutinized the administrative record and recommended
that BCBS uphold the denial of benefits. He cited the
absence of any medical necessity for the placement and
reiterated the conclusions of the first psychiatrist-
reviewer. On June 19, 2013, BCBS denied the internal
appeal in a letter to Stephanie.
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judgment, and the district court entered judgment in favor of BCBS.
See Stephanie C. v. Blue Cross Blue Shield of Mass. HMO Blue, Inc.,
No. 13-13250, 2015 WL 1443012, at *12 (D. Mass. Mar. 29, 2015).
Stephanie appealed.
that the court should have reviewed the denial de novo because the
id. (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101,
429.
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(Stephanie II), No. 13-13250, 2016 WL 3636978, at *4 (D. Mass.
court's decision.
see, e.g., Murray v. Kindred Nursing Ctrs. W. LLC, 789 F.3d 20, 25
F.3d 178, 184 (1st Cir. 1999), and that standard is not altered by
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The rationale behind this practice is straightforward.
matter of law? See Fed. R. Civ. P. 56(a); Murray, 789 F.3d at 25.
ends; if the answers are in the negative, the case is set for
trial.
838 F.3d 42, 47 (1st Cir. 2016). "That the parties brought the
Hosp., Inc. v. Thompson, 308 F.3d 91, 97-98 (1st Cir. 2002). The
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Liberty Life Assur. Co., 566 F.3d 1, 10 (1st Cir. 2009). Such
Shipping Ass'n, 471 F.3d 229, 235 (1st Cir. 2006) (explaining that
Puerto Rico, Inc. for the proposition that the intent of the
parties at the time they moved for summary judgment ought to govern
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administrative record; it was, instead, a garden-variety
which "the parties waive trial and present the case to the court
(quoting TLT Constr. Corp. v. RI, Inc., 484 F.3d 130, 135 n.6 (1st
held that the district court should not have decided the summary
2
De novo review differs significantly from clear error
review. Compare Leahy v. Raytheon Co., 315 F.3d 11, 16 (1st Cir.
2002) (stating that, under de novo review, "the court of appeals
must decide [the relevant issues] for itself"), and United States
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Logically, the nature of the district court's review
Mut. Life Ins. Co., 640 F.3d 27, 34 (1st Cir. 2011). In that
See Colby v. Union Sec. Ins. Co. & Mgmt. Co. for Merrimack
Anesthesia Assocs. Long Term Disab. Plan, 705 F.3d 58, 61 n.2 (1st
court may weigh the facts, resolve conflicts in the evidence, and
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Co., 404 F.3d 510, 518 (1st Cir. 2005). In such cases, the argument
had been wrongfully terminated. See 454 F.3d 69, 72 (1st Cir.
judgment for the fiduciary. See id. Noting that "the parties
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record" of the proceedings before the plan administrator, we held
Ben. Serv. Co., 423 F.3d 6, 13 (1st Cir. 2005) (reviewing factual
clear error).
sometimes they do not. In the last analysis, this case falls into
the latter camp: we have examined the record with care, and we are
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III. THE MERITS
fact entitled to coverage. See Gent v. CUNA Mut. Ins. Soc'y, 611
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[t]hese programs may have educational accreditation.
The staff may include some licensed mental health
providers who may provide some therapy. No benefits are
provided for any services furnished along with one of
these non-covered programs. For example, no benefits
are provided for therapy and/or psychotherapy furnished
along with one of these non-covered programs.
and grade-point averages. Nor does she dispute that Gateway refers
that "[n]o benefits are provided for any services furnished along
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Stephanie has a fallback position. She contends that
BCBS did not properly notify her that Gateway's educational setting
Glista v. Unum Life Ins. Co., 378 F.3d 113, 128-32 (1st Cir. 2004).
BCBS "will send you and/or the health care provider" notice of the
reason for the denial. The pronoun "you" is defined as "any member
who has the right to the coverage provided by this health plan. A
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Stephanie does not dispute that M.G.'s father was a
beneficiary whose claim for benefits under the plan has been
denied, setting forth the specific reasons for such denial, written
Union v. Superline Transp. Co., 953 F.2d 17, 21 (1st Cir. 1992)
squarely in the lower court cannot be broached for the first time
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the educational setting bar to coverage, adumbrated in the
district court's second ground for denying the claim: that M.G.'s
WL 3636978, at *3.
Packard Corp., 592 F.3d 232, 239 (1st Cir. 2010). Indeed, even
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To facilitate this decisionmaking, BCBS reviewers
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of several enumerated behaviors. One such enumerated behavior is
criteria.
care (that is, a level of care less intensive than the Gateway
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satisfied either of these requirements. See Stephanie II, 2016 WL
too, the discharge summary disclosed that M.G. had "reduced his
the fact that M.G. required further treatment did not mean that
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render his prior treatment unsuccessful. Stephanie does not
year prior to commencing the Gateway program. She notes that M.G.
arrested the following month for hitting her. While this incident
has carried her burden of demonstrating that M.G. had the required
that Stephanie's proof fell short in yet another respect: M.G. had
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applied the less onerous standards specified for a "Psychiatric
policy."
settings.
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"organizational policy" is undefined, one use of it is in the
settings. Cf. Gustafson v. Alloyd Co., 513 U.S. 561, 568 (1995)
Smart v. Gillette Co. Long-Term Disab. Plan, 70 F.3d 173, 179 (1st
organizational policy.
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somewhere between traditional inpatient and outpatient care
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To sum up, an ERISA plan is a form of contract. See
Filiatrault v. Comverse Tech., Inc., 275 F.3d 131, 135 (1st Cir.
him but, rather, whether that course of treatment was covered under
the Plan. Applying the plain language of the Plan, we hold that
IV. CONCLUSION
Affirmed.
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