Easter v. Cayuga Med. Ctr. at Ithaca Prepaid Health Plan

217 F.Supp.3d 608

Jennifer EASTER, individually and on behalf of B.E., a minor, Plaintiffs,

v.CAYUGA MEDICAL CENTER AT ITHACA PREPAID HEALTH PLAN, Cayuga Medical Center at Ithaca, and Excellus Health Plan, Inc., d/b/a Excellus BlueCross Blueshield, Defendants.

5:14–CV–1403 (BKS/TWD)

United States District Court, N.D. New York.

Signed November 15, 2016

For Plaintiffs: Carla N. McKain, Esq., McKain Law, PLLC, 136 E. State St.,

Ithaca, NY 14850, Oliver N. Blaise, III, Esq., Coughlin & Gerhart, LLP, 99 Corporate Drive, Binghamton, NY 13904

For Defendants Cayuga Medical Center at Ithaca Prepaid Health Plan and Cayuga Medical Center at Ithaca: Christina M. Petrella, Esq., Harris Beach PLLC, 99 Garnsey Road, Pittsford, NY 14534

For Defendant Excellus: Robert Kirchner, Esq., John P. Wright Jr., Esq., Bond, Schoeneck & King, PLLC, One Lincoln Center, Syracuse, NY 13202

MEMORANDUM–DECISION AND ORDER

Hon. Brenda K. Sannes, United States District Court Judge:

I. INTRODUCTION

Plaintiff Jennifer Easter brings this action on behalf of her son, B.E., under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001, et seq. In the Second Amended Complaint, Plaintiffs allege that Defendants Cayuga Medical Center at Ithaca Prepaid Health Plan ("Plan"), Cayuga Medical Center ("CMC"),¹ and Excellus Health Plan, Inc. ("Excellus") violated ERISA with their "denial of Plaintiffs' claims for medical benefits and failure to provide requested information." (Dkt. No. 27, p. 1). Currently pending before the Court are the CMC Defendants' motion for summary judgment (Dkt. No. 41), Excellus' motion for summary judgment (Dkt. No. 42), and Plaintiffs' cross-motion for summary judgment (Dkt. No. 43). For the reasons set forth below, each party's motion for summary judgment is granted in part and denied in part. The Court remands consideration of Plaintiffs' claims for benefits to Defendants for renewed consideration in accordance with this Opinion.

II. BACKGROUND²

A. Plaintiffs' Allegations Regarding B.E.'s Treatment History³

B.E. is a minor dependent of Plaintiff Easter, who is an employee of the Cayuga Medical Center at Ithaca. (Dkt. No. 43–3, ¶¶ 5–6; Dkt. No. 47–1, ¶¶ 5–6; Dkt. No. 48–1, ¶¶ 5–6). In 2006, when B.E. was eight years old, he received a "speech articulation evaluation at the Sir Alexander Ewing–Ithaca College Speech and Hearing Clinic" and was subsequently "referred for a comprehensive psychological education evaluation to aide [sic] in school placement and instructional planning." (Dkt. No. 27, ¶ 14; Dkt. No. 27–2, p. 2). A series of tests performed by a psychologist "showed diversely developed cognitive abilities and inconsistencies in performance that are associated with learning disabilities" and the psychologist "recommended specific supportive strategies to improve B.E.'s academic performance." (Dkt. No. 27, ¶ 16; Dkt. No. 27–2, pp. 5, 10–11).

In 2009, when B.E. was eleven years old, school personnel "referred [him] for psychotherapy and [he] began working with ... a licensed therapist" over weekly out-patient meetings "to assist B.E. in managing distractibility, frustration, and organizational tasks." (Dkt. No. 27, ¶¶ 16–17; Dkt. 27–3, p. 2). The therapist "diagnosed B.E. with dysthymia..., a reading disorder, an anxiety disorder not specified, and educational problems." (Dkt. No. 27, ¶ 18; Dkt. No. 27–3, p. 2). Though B.E. "initially responded well to traditional therapy," his progress "decline[d] considerably." (Dkt. No. 27, ¶ 19; Dkt. No. 27–3, pp. 2–3).

In this period, B.E. also "underwent a Comprehensive Neurodevelopmental Assessment at the Yellin Center for Student Success in New York City to obtain a learning profile which was used by B.E.'s elementary school to help B.E. academically." (Dkt. No. 27, ¶ 20; Dkt. No. 27–3, p. 3). B.E.'s parents "continued to consult with several doctors" through early 2010 "to evaluate and treat B.E.'s dysthymia and anxiety." (Dkt. No. 27, ¶ 21; Dkt. No. 27–3, p. 3).

"As B.E. entered adolescence, [his] emotional and academic functioning steadily deteriorated, and B.E.'s behavior raised concerns about both B.E.'s and others' safety." (Dkt. No. 27, ¶ 22; Dkt. No. 27–3, p. 3). Plaintiffs assert that relevant symptoms and incidents included: (1) "night terrors on a regular basis" that were "extremely violent and scary" and sometimes caused B.E. to be "afraid to go to sleep;" (2) "seem[ing] sad[ ] and develop[ing] a profound lack of interest and a loss of enthusiasm in doing most things;" (3) "irrational fears ... including a recurring fear that the sun would burn the earth," which would "very often ... when it was a bright, sunny morning" cause B.E. to "become anxious and panic because [he] was fearful the sun was falling from the sky;" (4) repeated threats to jump from moving vehicles, including an incident on the highway where he also "threatened to grab the steering wheel and crash the car;" (5) "physically aggressive" behaviors that made Easter "ready to call 911" or leave the house "out of fear ... in hopes that B.E. would calm down;" (6) running away; and (7) threats of self-harm and suicide. (Dkt. No. 27, ¶ 22).

In May 2012, a doctor diagnosed B.E. with "conduct disorder; mixed mood and anxiety disorder; a learning disability in language, reading, memory, and sequencing; and antisocial personality disorder." (Id. at ¶ 23; Dkt. No. 27–4, p. 4). Despite attempts to utilize "comprehensive, multifaceted out-patient treatment ..., B.E. had increasing problems with anger, mood swings, [ ] unpredictable behavior, declining academic performance, and learning disabilities." (Dkt. No. 27, ¶ 24; Dkt. No. 27–3, p. 3). Consequently, B.E.'s parents consulted with an educational specialist "to help find a residential treatment facility that would meet B.E.'s needs." (Dkt. No. 27, ¶ 25; Dkt. No. 27–5, p. 2). In October 2012, following consultation with other specialists including B.E.'s therapist, the consultant "developed a treatment plan for B.E. taking into consideration [his] diagnoses and other evident challenges, including a mood disorder, anxiety, adoption issues, racial-identity developmental issues, gender-orientation issues, anger management, and learning disabilities." (Dkt. No. 27, ¶ 27; Dkt. No. 27–5, pp. 2–3). According to the plan, that "there were no facilities in close proximity that met B.E.'s complex needs" and recommended a "short-term intensive program that would be followed by a longer-term residential program." (Dkt. No. 27, ¶¶ 28–29; Dkt. No. 27–5, p. 3).

For the short-term program, B.E. entered the Second Nature Wilderness Program, "a licensed adolescent treatment program," in November 2012. (Dkt. No. 27, ¶ 30; Dkt. No. 27–6, p. 2). A doctor who worked with B.E. during the program recommended that B.E. "be followed closely by a child and adolescent psychiatrist as medications may continue to be an important part of [his] ongoing treatment" and indicated a belief that B.E. "would certainly do best in a residential treatment setting that can address all of [his] issues at once." (Dkt. No. 27, ¶ 31; Dkt. No. 27–7, p. 19) (internal quotation marks omitted). "On discharge from [the program] in February 2013, B.E. had diagnoses of pervasive development disorder not otherwise specified (NOS), depressive disorder NOS, reading disorder, disruptive behavior disorder NOS, and parent/child relational problems." (Dkt. No. 27, ¶ 32; Dkt. No. 27–6, p. 2). A doctor from the program stated in B.E.'s "Discharge Summary" that a return to B.E.'s home environment "would most certainly result in significant regression and a return to [his] previous level of functioning." (Dkt. No. 27, ¶ 33; Dkt. No. 17–6, p. 4).

On February 5, 2013, B.E. was admitted to Maple Lake Academy ("Maple Lake") in Utah (Dkt. No. 27, ¶¶ 35–36; Dkt. No. 27–8, p. 2), a facility licensed by the State "to provide residential treatment." (Dkt. No. 45–5). Patti Hollenbeck–Dial, one of its founders and owners who has "a doctorate in Marriage and Family Therapy" and has "specialized in working as a therapist with adolescents," stated in an affidavit that Maple Lake "provides 24–hour continuous, individually-planned residential treatment including daily clinical assessment, a structured daily therapeutic program that provides a minimum of 20 hours of therapy per week, daily medication management, 24–hour-per-day on-site supervision, a full-time nurse, a part-time child-adolescent psychiatrist, and discharge planning." (Dkt. No. 45–4, ¶¶ 1, 6). Hollenbeck–Dial also stated that "[p]rograms such as the one offered by Maple Lake to children like B.E. are a critical intermediate level of care between inpatient and outpatient treatment of mental, emotional, and behavioral conditions" and that "without an intermediate level of care and constant supervision, children with conditions such as those B.E. had in 2014 are likely to have worsening psychiatric, emotional, and cognitive problems." (Id. at ¶¶ 11–12). B.E.'s treatments at Maple Lake included "weekly individual therapy, weekly family therapy, daily group therapy, full participation in a residential program, participation in daily chores and exercise, as well as educational instruction." (Dkt. No. 27, ¶ 38; Dkt. No. 27–8, pp. 3–7). B.E. remained at Maple Lake through most of 2014, before admission to another facility in the end of that year.⁴

B. The Cayuga Medical Center Health Plan

"Cayuga Medical Center at Ithaca Prepaid Health Plan [ ('Plan') ] is a self-funded employer-provided welfare benefit plan," for which Cayuga Medical Center at Ithaca ("CMC") "is the Plan Sponsor, Plan Administrator and a named fiduciary." (Dkt. No. 43–3, ¶ 1–2; Dkt. No. 47–1, ¶ 1–2; Dkt. No. 48–1, ¶¶ 1–2). Under the terms of Defendants' Administrative Services Contract ("ASC"), Excellus Health Plan, Inc. ("Excellus"), a licensee of the BlueCross Blue Shield Association, is "the Plan's third-party claims administrator," which "processes claims and determines benefits" for the Plan. (Dkt. No....