Boyd v. Sysco Corp.

Wayne Boyd and Whitfield R. Boyd, Plaintiffs, v. Sysco Corporation, Sysco Corporation Group Benefit Plan,and United Behavioral Health, Defendants.

Civil Action No.: 4:13-cv-00599-RBH

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF SOUTH CAROLINA FLORENCE DIVISION

December 1, 2015

OPINION AND ORDER

Pending before the court are the parties' memoranda in support of judgment.¹ Plaintiffs assert entitlement to certain benefits pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"), ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B) (i.e., a claim for benefits)², and request attorney's fees pursuant to ERISA § 502(g), 29 U.S.C. § 1132(g), and prejudgment interest.³

The parties entered into a Joint Stipulation agreeing to certain relevant portions of the administrative record and certain relevant portions of the plan documents. However, Plaintiffs do not stipulate that this is the complete record due to "Defendants' many errors and omissions incompiling the record". (Jt. Stipulation, ECF No. 48, p. 4) Plaintiffs also object to the defendants' inclusion in the record of a document entitled "Practice Guideline for the Treatment of Patients with Substance Use Disorders, Second Edition", by the American Psychiatric Association (APA), UBH 916-923, on the basis that it was not furnished to the plaintiffs in response to the limited requests for production of documents authorized by the Court and was disclosed for the first time on the day before the deadline for filing memoranda in support of judgment. The parties also do not agree on the appropriate scope of this Court's review. The defendants assert that an abuse of discretion scope of review applies because the plan documents confer discretion upon them to interpret the plan. They also assert that the Plan Administrator has delegated that discretion to UBH, the Claims Administrator. The plaintiffs contend that, although the Plan language appears to vest discretion in Sysco, "repeated procedural and substantive violations by Defendant mean that this Court should review the administrative denials de novo." (Jt. Stipulation, p. 2, ECF No. 48) The parties agree that the standard of review is not affected by a conflict of interest, as the Plan is self-funded by Sysco, and UBH is the claims administrator. The parties also agree that the Court may dispose of this matter based upon the joint stipulation, the attachments thereto, and the memoranda in support of judgment, except that the plaintiffs assert that the Court may also need to reference Plaintiff's Motion for Discovery and related filings, Defendants' discovery responses to the limited discovery allowed by the Court, and the plaintiffs' motion to compel.⁴

Procedural Overview

Plaintiff Wayne Boyd's employer, Sysco Corporation, ("Sysco") established an employee welfare benefit plan to provide various benefits to employees and their families. The plan is entitled "Sysco Corporation Group Benefit Plan" ("the Plan") (UBH 0870-0900). Under the Plan documents, Sysco is the plan administrator, and the Plan Administrator may delegate its duties and discretionary authority to a third party Claims Administrator.⁵ Defendant United Behavioral Health (UBH) is the Plan's designated Claims Administrator for mental health and substance abuse claims. (2009 Benefits Guide-Summary Plan Description (SPD) (UBH 0018)). Wayne Boyd was a participant in the Plan and his son, Whitfield R. Boyd ("Boyd") was a covered beneficiary.

The Plan provides⁶ that a covered medical expense "must be medically necessary, must meet accepted standards, must be covered by the Healthcare Program." (UBH 103) The Plan does not cover services that "are not medically necessary, as determined by the claims administrator." (UBH 106) The Glossary of Key Terms for Healthcare Program contains the following definitions:

Medically Necessary. A treatment, confinement or service prescribed by a physician which is determined by the Claims Administrator to be necessary and appropriate for the diagnosis, care or treatment of the disease or injury involved, non-experimental or non-investigational and not in conflict with accepted medical standards.

(UBH 0155)

The Plan provides for an initial claims determination and an appeal within the Plan. (UBH 0880-0881)

Factual Background and Filing of Claim

A. Plaintiff Whitfield Boyd's Claim for Benefits for Residential Substance Abuse Treatment.

This case involves Boyd's claim for mental health/substance abuse benefits under the Plan for treatment received by him at a residential rehabilitation program, Narconon Vista Bay, California, from July 23, 2010 through August 26, 2010.⁷ The administrative record contains an affidavit by Wayne Boyd which was submitted to UBH on November 19, 2012 by counsel for the plaintiff⁸ in which Mr. Boyd summarizes the history of his son's drug addiction and the unsuccessful treatments that he underwent before his stay at Narconon at Three Rivers Rehab in Columbia, South Carolina in 2006,⁹ Wilmington Treatment Center in Wilmington, North Carolina in 2008¹⁰, and a methodone clinic. He states that he put his son on the plane to California on July 13, 2010 for detox treatment; that he notified UBH on the next day (July 14, 2010) by telephone; and that the UBH representative told him that the Narconon treatment would be covered but that a $400 penalty would be imposed for going out of network. (UBH 0904) The affidavit does not mention August West Family Services, the medical dotoxification facility where Boyd received treatment beginning on July 13, 2010, immediately prior to the Narconon stay. The affidavit simply states that Narconon Vista Bay agreed to accept Boyd the day after hisparents called. It then states: "They met him in San Francisco and escorted him to a medical facility to help him start the initial detox." (UBH 903) The record is not clear as to the connection, if any, between August West and Narconon.

At the time of his admission to August West on July 13, 2010, Boyd had been using "3x2 [Xanax] bars x 1 year" and "Suboxone x 2 years." The Suboxone dose was 24 mg daily. (UBH 0793, 0798) He was, upon admission, "poly drug dependent: Xanax + Suboxone." (UBH 0793) Those facts are listed under "Axis I," which is the category in the DSM for acute conditions needing treatment. (UBH 0793) Under close supervision by physicians at August West, Boyd was tapered off of Suboxone and Xanax and prescribed phenobarbital for alcohol withdrawal. (UBH 0794-798) The records reflect tremors, sweats, diarrhea, anxiety/agitation, muscle cramping and sleeplessness. (UBH 0801) Boyd went through withdrawal for ten days, with the withdrawal symptoms gradually decreasing over the course of the ten day medical treatment (UBH 0799). The taper (i.e., a physician prescribing smaller and smaller dosages of the drugs to which he was addicted) lasted through July 22, 2014, the date on which Boyd took his last tapered dose of suboxone. (UBH 0797) The July 22 medical record states that Boyd "completed his detox protocol and will transition to [Narconon] tomorrow to begin his program." (UBH 0799) Boyd then transferred directly to the longer-term rehab program at Narconon. Upon admission, Boyd's doctor noted his "second failed rehab." He also noted "opiate dependence" and "new tracks" (i.e, new needle marks in Boyd's arms). (UBH 0611) Boyd completed a drug history upon his arrival at Narconon that showed his oxycontin use started eight years prior, and his Xanax use started six to seven years prior. (UBH 0625). The history given at Narconon also showed use of heroin, cocaine, crack cocaine, hashish, marijuana, LSD, PCP, and Ecstacy. (UBH 0625) The Narcononrecords reflect that Boyd had continued using oxycontin and Xanax right up until July 12, 2010, the day before his trip to California. (UBH 0625) In the thirty days leading to that admission, he had used more than one drug twenty-seven out of thirty days. (UBH 0626). Boyd stayed in the Narconon program for its full course, successfully completed it, and was discharged on December 18, 2010. According to Boyd, "I can state with no hesitation that my rehab at Narconon saved my life." (UBH 0255)

B. UBH Case Notes.

The internal UBH Case Notes indicate that Wayne Boyd called UBH on October 7, 2010 and stated that he was "looking for benefits for OON facility where his son is staying" and that the facility had been billing the wrong insurance company. (UBH 0314) In a Retrospective Review on July 7, 2011, the case was summarized as follows:

23 yr old mbr admitted for treatment of opiate dependence. Med record: 8271117590464. Drug of choice: oxycontin 80 mg/heroin .2, both daily. Previous treatment is two programs, level of care not indicated. The information is primarily intake information. There are no clinical progress notes by any mental health staff so it is not clear what kind of treatment occurred, interventions used or when the member was discharged. Hence no decision can be made re: med nec for continued treatment at this level of care or what kind of care was provided . . . Will advise claims dept to obtain a complete med record." (UBH 0316)

In a Retrospective Review dated August 9, 2011, the case manager's assessment is as follows:

THE TREATMENT MODEL DOES NOT MEET UBH LEVEL OF CARE GUIDELINES AND BEST PRACTICE GUIDELINES AS DEFINED BY THE APA¹¹. THE MODEL FOR THIS PROGRAM . . . DOES NOT MEET LEVEL OF CARE GUIDELINES AS DEFINED BY UBH. IT IS A DRUG-FREE EDUCATIONAL PROGRAM, COMPRISED OF A PRESCRIBED SERIES OF

COURSES AND WORKSHOPS. DETOXIFICATION IS ACCOMPLISHED BY SAUNA, EXERCISE, AND NUTRITIONAL SUPPLEMENTS.

Level of Care Guidelines not met: "Any one of the following", 2a, b; 3, 5a, 7b. Also, the treatment model is not consistent with APA Best Practices Guidelines (can be found at www.psychiatryonline.com-Section I, Executive Summary, B, General Treatment Principles.

The reviewer also noted that medical records had been received by UBH on 6-24-11. However, the note does...