1. Case Name: Kimberley D. v. United Healthcare Insurance Company
2. Type of Treatment Services Denied: Residential Treatment
- Plaintiff: Lisa Kantor and Peter Sessions, Kantor & Kantor, LLP
- Defendant: Raul Martinez and Elise Klein, Lewis, Brisbois, Bisgaard & Smith, LLC
4. Format: Memorandum from appeal of district court’s judgment in favor of the United Healthcare Insurance Company
- ERISA Claim? Yes
- Class Action/or Individual Action: Individual
- Defendant: Health Plan
- Type of Insurance Plan: Employee Welfare Benefit Plan regulated by ERISA
- Type of Coverage Denial: Medical Necessity
6. Legal Pointer: These are the same guidelines argued to be invalid in the Wit v. United case, 3:14-cv-02346-JCS.
7. Legal Issues and Causes of Action: Appellant appealed the district court’s judgment in favor of the United Healthcare Insurance Company, affirming denial of benefits.
- Ruling: The district court did not err when determining whether Appellant’s stay at Sierra Tucson was medically necessary as covered by the Plan. Appellant failed to show by a preponderance of the evidence that the treatment she received ay Sierra Tucson was medically necessary or in compliance with United’s applicable guidelines.
8. Narrative Case Description: Kimberley D. suffers from mental illnesses, including an eating disorder, major depressive disorder, and generalized anxiety disorder. Kimberley attempted outpatient treatment without much success and was recommended for residential treatment at Sierra Tucson, a mental health facility in Arizona, in order to address her issues. Upon admission, Kimberley underwent several examinations which revealed that her suicide risk was high. Her risk was sufficiently elevated that Sierra Tucson required Kimberley to sign a no-harm contract upon entering treatment. While at Sierra Tucson, Kimberley’s suicidality increased. She informed staff that if she were released from treatment, she had a plan to kill herself by renting a hotel room and taking all of her pills. Despite these facts, United denied Kimberley’s insurance claim for benefits for her treatment at Sierra Tucson, and the district court upheld this decision.
Appellant contends that United’s denial was not supported by the record and was contrary to the guidelines used both by United and treating professionals in the mental health field. She further contends that Kimberley’s life would have been in jeopardy if she had left residential treatment.
Appellee contends that Kimberley did “not meet Optum Health’s 2014 Level of Care Guidelines, Mental Health Conditions: Residential Treatment Center medical necessity criteria” because her condition was stable, she was not experiencing any acute medical complications, her mood was moderate in severity and her behavior was well-controlled, Furthermore, she was described as cooperative and appropriate with others, compliant with treatment recommendations and there was no acting out behaviors to suggest impulse control problems or risk of harm. It was concluded that Kimberley could maintain stability and continue progress in her recovery with ongoing treatment in a less restrictive care setting.
The Appellate Court stated that the Plan provides that medically necessary treatment is “clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective…” The treatment must not be “mainly for [claimant’s] convenience or that of [their] doctor or other health care provider,” and must also not be “more costly than an alternative…service…,”” Medically necessary treatment must be “in accordance with Generally Accepted Standards of Medical Practice,” which are based on clinical policies developed and maintained by United Healthcare. Upon intake at Sierra Tucson, Appellant reported her primary problems as binge eating, isolation and poor body image. During her intake evaluation, treating physician Dr. Sipp noted that Appellant denied active suicidal ideation and had no “plan or intent to harm herself or harm others.” United’s Dr. Uy reviewed Appellant’s intake evaluation for authorization and concluded that coverage was not available under the Plan, because she did not meet the level of care guidelines. Dr. Uy explained that because Appellant was stable and not presenting active suicidal ideation, she could be treated in a less restrictive care setting. When Appellant appealed Dr. Uy’s conclusion, United’s Dr. Sane found, as had Dr. Uy, that the level of care guidelines did not specify residential care for Appellant’s reported symptoms. Appellant repeatedly denied suicide ideation and it was not until after earning she was denied coverage that she expressed active suicidal thoughts.
9. Additional Comments: None.
11. Practical Implications and Lessons Learned: None.
12. All Legal Theories Presented in Case: Breach of ERISA
13. Successful Legal Theories in Case: None.