David P. & L.P. v. United Healthcare Ins. Co.

564 F.Supp.3d 1100

DAVID P. and L.P., Plaintiffs,

v.UNITED HEALTHCARE INSURANCE COMPANY, Morgan Stanley Chief Human Resources Officer and the Morgan Stanley Medical Plan, Defendants.

Case No. 2:19-cv-00225-JNP-JCB

United States District Court, D. Utah.

Signed September 29, 2021

Brian S. King, Samuel Martin Hall, Brent J. Newton, Brian S. King PC, Nediha Hadzikadunic, Gross & Rooney, Salt Lake City, UT, for Plaintiffs.

Clint R. Hansen, Scott M. Petersen, Fabian Vancott, Salt Lake City, UT, Michael H. Bernstein, Pro Hac Vice, Robinson & Cole LLC, New York, NY, for Defendants.

MEMORANDUM DECISION AND ORDER GRANTING PLAINTIFFS’ MOTION FOR SUMMARY JUDGMENT AND DENYING DEFENDANTS’ MOTION FOR SUMMARY JUDGMENT

Jill N. Parrish, United States District Court Judge

This action arises under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001, et seq. , and is before the court on the parties’ cross-motions for summary judgment. Plaintiffs’ complaint alleges two causes of action: (1) recovery of benefits under 29 U.S.C. § 1132(a)(1)(B) ("ERISA claim") and (2) violation of the Mental Health Parity and Addiction Equity Act under 29 U.S.C. § 1132(a)(3) ("Parity Act claim"). Defendants United Healthcare Insurance Company ("United"), Morgan Stanley Chief Human Resources Officer, and the Morgan Stanley Medical Plan (collectively, "Defendants") moved for summary judgment on both causes of action on December 4, 2020. Plaintiffs David P. and L.P. (collectively, "Plaintiffs") moved for partial summary judgment on the ERISA claim on December 4, 2020, and requested an extension of the dispositive motion deadline. Defendants agreed to withdraw their summary judgment motion as it related to the Parity Act and the parties continued to brief their cross-motions for summary judgment on the Parity Act claim. Defendants moved for partial summary judgment on the Parity Act claim on May 14, 2021. Plaintiffs filed their cross-motion for partial summary judgment on the Parity Act claim on May 18, 2021.

BACKGROUND

This dispute involves the denial of benefits allegedly due to Plaintiffs under their ERISA employee group health benefit plan, the Morgan Stanley Medical Plan ("the Plan"). Morgan Stanley is the Plan Sponsor and Morgan Stanley's Chief Human Resources Officer is the Plan Administrator. Rec. 206. United administers claims for mental health and substance abuse benefits under the Plan through its Mental Health and Substance Abuse Claims Administrator, United Behavioral Health ("UBH"). Id. 268. Under the Plan, UBH has discretionary authority to interpret Plan provisions, set coverage criteria consistent with the Plan, and make decisions regarding specific claims for benefits and appeals of benefit denials. Id. 210. David P. was a Plan participant at all times relevant to the claims in this case and his daughter, L.P., was a Plan beneficiary. Compl. ¶ 5.

Plaintiffs sought care for L.P.’s mental health and substance abuse conditions at two successive Residential Treatment Centers ("RTCs"), first at Summit Achievement ("Summit") in Maine and then at Uinta Academy ("Uinta") in Utah. Id. ¶ 6. L.P. received care at Summit from November 28, 2016, to February 13, 2017, and at Uinta from February 14, 2017, to November 30, 2017. Id. UBH denied benefits for the duration of L.P.’s stay at Summit. UBH elected to cover the first eight days of L.P.’s treatment at Uinta but denied benefits for the remainder of her stay at Uinta. Id. ¶¶ 20, 36-37. Plaintiffs contend that UBH's denial of benefits caused them to pay over $177,000 in unreimbursed, out-of-pocket expenses. Id. ¶ 62.

I. THE PLAN

The Plan offers benefits for medically necessary mental health and substance abuse care. Rec. 213. The Plan defines medically necessary services as those

• Provided for the diagnosis, treatment, cure or relief of a health condition, illness, injury, or disease;

• Not for experimental, investigational or cosmetic purposes;

• Necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease or its symptoms;

• Within generally accepted standards of medical care in the community; and

• Not solely for the convenience of the employee, the employee's family or the provider.

Id. In general, the Plan excludes coverage for "[a]ny services, treatments or supplies that are not medically necessary for the prevention, diagnosis or treatment of an illness, injury or pregnancy." Id. 74.

UBH maintains Level of Care Guidelines ("UBH Guidelines") that provide a set of objective criteria to determine medical necessity, thus standardizing coverage determinations. Id. 433. The UBH Guidelines define a Residential Treatment Center as a "sub-acute facility-based program which delivers 24-hour/7-day assessment and diagnostic services, and active behavioral health treatment to members who do not require the intensity of nursing care, medical monitoring and physician availability offered in Inpatient." Id. 430. Under its delegated authority to interpret the Plan and develop claims administration criteria, UBH uses two sets of medical necessity criteria to make benefits determinations for RTC treatment. In addition to general eligibility requirements, UBH's admissions criteria for RTC treatment requires claimants to meet each of the following:

1. The member's current condition cannot be safely, efficiently, and effectively assessed and/or treated in a less intensive level of care, and

2. The member's current condition can be safely, efficiently, and effectively assessed and/or treated in the proposed level of care, and

3. Co-occurring behavioral health and medical conditions can be safely managed, and

4. Services are consistent with generally accepted standards of clinical practice, with services backed by credible research, and with Optum's best practice guidelines, and

5. There is a reasonable expectation that service(s) will improve the member's presenting problems within a reasonable period of time, and

6. The member is not in imminent or current risk of harm to self, others, and/or property, and 7. The "why now" factors leading to admission cannot be safely, efficiently, or effectively assessed and/or treated in a less intensive setting due to acute changes in the member's signs and symptoms and/or psychosocial factors.

Id. 434, 441-42. UBH's continued care criteria for RTC care requires claimants to meet all of the following to remain in RTC care:

1. The admission criteria continue to be met and active (i.e., a supervised individualized treatment plan) treatment is being provided, and

2. The factors leading to admission have been identified and are integrated into the treatment and discharge plans, and

3. Clinical best practices are being provided with sufficient intensity to address the member's treatment needs, and

4. The member's family and other natural resources are engaged to participate in the member's treatment as clinically indicated, and

5. Treatment is not primarily for the purpose of providing custodial care.

Id.

II. L.P.'S CONDITION

Aside from a diagnosis of Attention Deficit Disorder ("ADD") in fourth grade, L.P. maintained a relatively typical childhood. Id. 489. However, when L.P. entered high school, her condition began to deteriorate. She struggled to connect with peers and became increasingly isolated. Id. L.P. reported hearing voices in her head and experienced anxiety attacks serious enough that her parents had to pick her up from school. Id. She began to cope by self-harming—burning, cutting, and tattooing her skin. Id. L.P. increasingly used drugs and alcohol. She brought alcohol to school and began driving while intoxicated. Id. 489, 491.

L.P.’s psychologist described her condition prior to being admitted to Summit by saying, "[s]he had numerous episodes of cutting, driving to endanger, being uncooperative and oppositional at home and in the community and has had significant opioid drug involvement." Id. 972. In fact, he reported that "[o]n November 5, 2016, [L.P.] cut herself deeply requiring hospitalization." Id. In her psychologist's opinion, "[o]utpatient therapy and psychopharmacological treatment with [L.P.] and her family were insufficient to address her emotional, psychological and physical needs." Id. Her psychologist recommended hospitalization "[o]n numerous occasions ... as [he] feared she might be a danger to herself or others." Id.

III. L.P.'S TREATMENT

L.P. was admitted to the RTC program at Summit on November 28, 2016. Treatment at Summit involves daily group therapy sessions, weekly individual counseling, and clinician-facilitated group therapy. Id. 997. A licensed clinical psychologist evaluated her approximately two weeks after arriving at Summit. Id. 1004. The psychologist noted that L.P. had "struggled with depression, suicidal thoughts, and self-harm" and that she continued to have suicidal thoughts while at Summit. Id. 1007-08. He ultimately diagnosed L.P. with generalized anxiety disorder ; major depressive disorder, recurrent, severe; some emerging traits consistent with borderline personality disorder ; cannabis use disorder; attention-deficit/hyperactivity disorder, combined presentation; and executive function deficit. Id. 1019. Summit developed a set of treatment goals to assist L.P. in her treatment at Summit. Id. 1065-68.

Following his assessment, and considering "the seriousness of these test findings," the psychologist "strongly recommended that following her discharge from Summit Achievement, [L.P.] go to a longer-term residential treatment program that can continue addressing each of these issues in depth." Id. 1018-19. L.P.’s Summit therapist also recommended long-term residential treatment "[d]ue to [L.P.’s] history of self-harm, substance abuse, risky behavior, and recent identification of emerging Borderline Personality Disorder." Id. 991. L.P. was discharged from Summit on February 13, 2017.

Based on the above recommendations, L.P.’s parents placed her at Uinta on February 14, 2017,...