1. Case Name: Todd R. v. Premera Blue Cross Blue Shield of Alaska
2. Type of Treatment Services Denied: Residential Treatment
- Plaintiff: Brian King, Brian S. King, PC
- Defendant: Jessica Wilde, Timothy Houpt, Jones Waldo Holbrook & McDonough
4. Format: Findings of Fact and Conclusions of Law and Order Regarding the Parties’ Cross Motions for Summary Judgment
- ERISA Claim? Yes
- Class Action/or Individual Action: Individual
- Defendant: Insurance Company
- Type of Insurance Plan: Fully Insured Employee Welfare Benefits Plan
- Type of Coverage Denial: Medical Necessity
6. Legal Pointer: The Court gave more weight to Lillian R.’s treating providers’ reports and opinions over the conclusions of Premera’s internal reviewer, review panel, and external reviewer.
7. Legal Issues and Causes of Action: The parties filed cross-Motions for Summary Judgment. Plaintiffs sought review of Premera’s denial of benefits under the plan. Specifically, Premera declined to cover a portion of Lillian R.’s stay at a residential treatment center as not medically necessary. Plaintiffs repeatedly appealed Premera’s decision, but at each level of review, the denial was affirmed. Plaintiffs therefore filed suit in an effort to recover the denied benefits.
Ruling: Based on the Court’s review of the record and its consideration of the parties’ arguments, the Court concluded that Lillian R.’s residential treatment at issue was medically necessary and therefore covered under the plan. Judgment was entered in favor of the Plaintiffs.
8. Narrative Case Description: Dr. Ghosh, a psychiatrist who treated Lillian R. from February 8, 2011 until July 16, 2013, concluded that inpatient residential care was the only treatment option for Lillian R. and recommended inpatient residential care because he was concerned for her safety. Mr. Summer, a licensed clinical social worker who worked with Lillian R. from March 20, 2013 to December 27, 2013, did not believe that there was any more that could be done for Lillian R. in an out-patient basis and recommended that her parents place her in residential treatment.
On or about December 31, 2013 or January 1, 2014, Lillian R.’s parents admitted her to residential treatment at Elevations Residential Treatment Center. Dr. Brockbank, an examining psychologist, conducted a comprehensive psychological evaluation of Lillian R. in February 2014, while she was undergoing treatment at Elevations. She strongly recommended that Lillian R. complete the program at Elevations and concluded that unless some change could occur on the family-system level, it was unlikely that Lillian R. would be successful at home. Lillian R. was treated at Elevations until June 21, 2015, when she was discharged.
Plaintiffs sought reimbursement from the Plan for the residential treatment that Lillian R. received at Elevations after April 30, 2014. On November 18, 2014, Premera denied Plaintiffs’ claims from May 1, 2014, through August 31, 2014, as untimely submitted and denied the claims from September 1, 2014, forward, as not medically necessary. On May 13, 2015, Plaintiffs appealed Premera’s denial of coverage through Premera’s internal appeal process (Level I Appeal). As a part of Plaintiffs’ Level I Appeal, Premera asked an Independent Physician Reviewer to review its decision to deny coverage. Dr. Holmes reviewed Plaintiffs’ Level I Appeal submissions and other relevant claim information and concluded that the service provided was not medically necessary. On August 10, 2015, Plaintiffs requested a Level II Appeal. To review Plaintiffs’ Level II Appeal and Lillian R.’s file, Premera assigned a panel consisting of (1) a physician who was a medical director and board certified in internal medicine, (2) a Member Contracts Operations Manager, and (3) a New Group and Product Implementation Manager. The Level II Appeal panel upheld Premera’s Level I Appeal determination denying coverage. On December 18, 2015, Plaintiffs requested an independent review of Premera’s decision. MCMC conducted the independent review and on January 14, 2016, Premera’s denial of coverage for Lillian R.’s residential treatment was upheld.
Suit was filed shortly thereafter, and the parties filed cross-Motions for Summary Judgment. Plaintiffs argued that the sixth risk listed in Premera’s Medical Policy provided that residential care was appropriate for an adolescent where the patient was stabilized during an inpatient treatment stay for severe symptoms or behavior and required a structured setting with continued around-the-clock behavioral care. Premera responded in two ways. First, in its November 18, 2014, denial letter, Premera stated that Lillian R.’s care did not fall with the sixth risk listed in Premera’s Medical Policy and therefore was not medically necessary because information from Elevations did not show evidence of the need for a structured setting and continued around-the-clock care to treat a severe mental health condition that partly stabilized during inpatient care. Second, at oral argument, Premera’s counsel argued that the sixth risk listed in the Medical Policy did not apply because it required the adolescent patient to have stabilized during an inpatient treatment stay for severe symptoms, and Lilian R.’s residential treatment stay at Elevations did not qualify as an inpatient treatment stay. Premera’s counsel argued that the term “inpatient” refered solely to inpatient hospital stays and not to residential treatment center stays, and thus, the sixth risk didinot apply because Lillian R. was never in inpatient hospitalization.
Plan Language and Medical Policy’ Sixth Risk
The Court concluded that the term “inpatient,” as it was used in the sixth risk listed in Premera’s Medical Policy, was not limited solely to hospital admissions but applied to admissions at other healthcare facilities, including residential treatment centers such as Elevations. Despite Premera’s argument that its Medical Policy limits the term “inpatient” to circumstances involving a hospital admission, the Court found no such limitation in the language of the Medical Policy. More specifically, the admission guidelines for adolescents to residential care contained in Premera’s Medical Policy did not (1) specifically define the term “inpatient” as that term was used in the sixth risk, or (2) expressly limit the term “inpatient” to mean only hospital admissions. Further, the terms “inpatient” and “residential care” were used interchangeably throughout the medical records and, moreover, Premera repeatedly described Lillian R.’s residential care at Elevations as “inpatient” throughout its own briefing. At oral argument, Premera’s counsel even agreed that the terms “residential” and “inpatient” were used interchangeably throughout the medical records. Thus, the Court concluded that the language of the Plan itself supported the conclusion that the term “inpatient” referred to a broader category of overnight stays than just hospitalizations. As such, Lillian R.’s treatment at Elevations fell within the Plan’s definition of “inpatient” as someone who was admitted to a healthcare facility for an overnight stay.
The Court also held that Lillian R.’s initial admission to Elevations was for severe symptoms as was also required under the sixth provision of Premera’s Medical Policy. During the months immediately preceding Lillian R.’s admission to Elevations, Lillian R. ran away from home twice, became assaultive with her mother and began self-injurious behaviors. Thus, the Court rejected Premera’s position at oral argument that the sixth risk contained in its Medical Policy was inapplicable because Lillian R.’s initial admission at Elevations was not for an inpatient treatment stay for severe symptoms.
Evidence of Medical Necessity
In its denial letter to Plaintiffs, Premera stated that Lillian R.’s stay at Elevations after April 30, 2014 did not fall with the sixth risk delineated in Premera’s Medical Policy and therefore was not medically necessary because information from Elevations did not show evidence of the need for a structured setting and continued around-the-clock care to treat a severe mental health condition that partly stabilized during inpatient care. In so concluding, the Court opined that Premera failed to adequately consider and/or evaluate certain portions of the medical record. Specifically, Premera did not adequately account for Dr. Brockbank’s February 2014 psychological evaluation of Lillian R. in which she strongly recommended that Lillian R. complete the program at Elevations due to Lillian R.’s history of running away and suicidal ideation.Dr. Brockbank’s assessment also supported the Court’s conclusion that Lillian R.’s continued treatment was medically necessary. In June 2014, just four months after Dr. Brockbank’s assessment, Lillian R. began once again to experience suicidal ideation and self-harm urges. Further, Lillian R. could not always make a commitment to her own safety or feel confident that she would notify staff before harming herself. Despite this critical evidence in support of the medical necessity of Lillian R’s continued participation in the Elevations residential treatment program, Premera never even discussed Dr. Brockbank’s evaluation in any of its briefing and the medical evaluations upon which Premera relied did not sufficiently account for Dr. Brockbank’s opinion or the medical records concerning Lillian R.’s propensity to self-harm. The Court concluded that, based on the records submitted, including Dr. Brockbank’s evaluation and recommendation that Lillian R. complete the Elevations program, along with other records that support Dr. Brockbank’s conclusion, including clinical notes showing that Lillian R. continued to experience suicidal and self-harm ideation and urges while at Elevations, Plaintiffs met their burden of proving that Lillian R.’s treatment at Elevations from May 1, 2014 to June 21, 2015 was medically necessary.
9. Additional Comments: None.
11. All Legal Theories Presented in Case: Breach of Fiduciary Duty in violation of ERISA
12. Successful Legal Theories in Case: Breach of Fiduciary Duty in violation of ERISA