1. Case Name: Baudoin v. Bluecross Blueshield of La.
2. Type of Treatment Services Denied: In-patient treatment for depression and polysubstance dependence
- Plaintiff: Larry E. Demmons, Taggart Morton, LLC
- Defendant: Charles A. O’Brien, III and Allison Nunley Pham
4. Format: Opinion on Petition for Damages, Penalties and Attorney’s Fees against Defendant
- ERISA Claim? Yes.
- Class Action/or Individual Action: Individual
- Defendant: Health Plan
- Type of Insurance Plan: Employer Plan under ERISA
- Type of Coverage Denial: Medical Necessity
6. Legal Pointer: None.
7. Legal Issues and Causes of Action: Plaintiffs allege that BCBS improperly denied mental health benefits for treatment received at two in-patient treatment facilities. Plaintiffs filed a Petition for Damages, Penalties and Attorney’s Fees.
- Ruling: Plaintiffs’ Petition was dismissed with prejudice at Plaintiffs’ costs.
8. Narrative Case Description: On October 15, 2010, Alex was experiencing severe depression and polysubstance dependence, and allegedly attempted suicide. Alex’s family coordinated a meeting with counselor, Roy Petitfils, who examined and evaluated Alex. Mr. Petitfils concluded that based upon Alex’s symptoms, Alex required 24-hour staff supervision and recommended that he be immediately placed in in-patient treatment. As such, Alex received in-patient treatment at The Meadows from October 21, 2010 through November 24, 2010. After leaving The Meadows, Alex was admitted to JayWalker for in-patient aftercare from November 27, 2010 until April 10, 2011. Plaintiffs filed claims for both treatment facilities. Magellan reviewed these claims and concluded that such treatment was not medically necessary.
BCBS argued that its interpretation of the Plan and its determination that Alex’s in-patient treatment was not medically necessary was consistent with a fair reading of the Plan. Plaintiffs argued that Alex’s in-patient treatment met the criteria for allowing benefits for in-patient treatment.
In order to determine if in-patient treatment was medically necessary, Magellan utilized the definition of medically necessary in the Plan along with its criteria for psychiatric in-patient hospitalization which BCBS asserts was developed by input from peer reviewed scientific literature, national mental health care standards, regulatory agencies and a behavioral health advisory committee made up of behavioral health care practitioners, network providers and national consultants. According to the plan and Magellan’s criteria, there must be a showing that the patient requires an individual plan of active psychiatric treatment that included 24-hour access to the full spectrum of psychiatric staffing. Magellan determined that Alex did not satisfy the medical necessity criteria because the medical and clinical records demonstrated that upon admission, Alex had stable vital signs, had no substance abuse relate withdrawals, was not an imminent danger to self or others, did not require 24-hour supervision, could have safely and effectively been treated in a less intensive level of care, had support available and had no history of seizures or complicated withdrawal symptoms.
While Plaintiffs suggested that Magellan’s determinations were in direct contradiction with an affidavit authored by Mr. Petitfils, the Court concluded that the Affidavit should not be given any weight since the date of his examination was months after Alex’s admission. The Court also found that Mr. Petitfils’ April 7, 2011 letter to Magellan that Alex met the criteria for a “substance dependence disorder” was not persuasive since the letter did not state when Mr. Petitfils met with Alex. Lastly, the Court held that Mr. Petitfils Affidavit and letter were also not persuasive since Mr. Peitfils is a counselor, not a physician or a psychiatrist.
The Court concluded that Plaintiffs failed to prove that the financial requirements and treatment limitations in the BCBS Plan and the criteria used by Magellan to determine medical necessity were more restrictive and/or more burdensome for mental health patients than for non-mental health patients.
9. Additional Comments: None.
10. Website: None.
11. Practical Implications and Lessons Learned: None.
12. All Legal Theories Presented in Case: Breach of fiduciary duties under ERISA, violation of Parity Act
13. Successful Legal Theories in Case: None.