United States District Court, E.D. Pennsylvania
Decided Date: August 26, 2014.
For KEVIN HURST, Plaintiff: ALAN H. CASPER, LEAD ATTORNEY, PHILADELPHIA, PA; LISA S. KANTOR, KANTOR & KANTOR LLP, NORTHRIDGE, CA.
For SIEMENS CORPORATION GROUP INSURANCE AND FLEXIBLE BENEFITS PROGRAMS, CIGNA BEHAVIORAL HEALTH, INC., Defendants: GREGORY GEORGE SCHWAB, JAMES A. KELLER, LEAD ATTORNEYS, SAUL EWING LLP, PHILADELPHIA, PA.
RONALD L. BUCKWALTER, SENIOR UNITED STATES DISTRICT JUDGE.
Currently pending before the Court is Defendants Siemens Corporation Group Insurance and Flexible Health Programs (" Siemens" ) and Cigna Behavioral Health, Inc. (" CBH" ) (collectively, " Defendants" )'s Motion for Summary Judgment as to all claims asserted by Plaintiff Kevin Hurst (" Plaintiff" ). For the following reasons, Defendants' Motion for Summary Judgment is granted.
I. FACTUAL HISTORY
Defendant Siemens is an employee welfare benefit plan (" the Plan" ) established by Siemens Corporation pursuant to ERISA, which is designed to provide health benefits to eligible employees and their dependents. (Defs.' Mem. Supp. Summ. J. 2.) Defendant CBH is the designated claim administrator for Siemen's Mental Health and Substance Abuse Program under the Plan. (Id.) Plaintiff, a Pennsylvania resident, is a covered participant in the Plan. (Id.)
A. The Plan Language
Under the Plan, CBH has full discretionary authority to interpret the terms of the Plan and to determine eligibility for benefits. (Id.) The Plan provides that:
[t]he determination of the Claims Administrator or Administrative Committee, as applicable, has full and exclusive discretionary authority to interpret all provisions of the Plans for which it is designated with responsibility for determining appeals, to determine material facts and eligibility for benefits, and to construe terms of the applicable Plan. Interpretations and determinations made by the Claims Administrator, or Administrative Committee, as applicable, with respect to the Plan for which it is designated responsibility for determining appeals, will be final, conclusive and binding; unless it can be shown that the interpretation or determination was arbitrary and capricious.
Administrative Record (" AR" ) 1126.) Diagnosis and treatment of mental illness, depression, and nervous disorders, as well as care for other emotional health needs, are covered by the Plan. (Pl.'s Resp. Opp'n Summ. J. 2 (citing AR1015).) Treatment at residential care facilities is also covered by the Plan. (Id. (citing AR1017, AR1189).)
To determine medical necessity and eligibility for residential treatment, CBH applies its Level of Care Guidelines for Behavioral Health & Substance Abuse (Defs.' Mem. Supp. Summ. J. 3 (citing AR0728-808).) CBH has specific Level of Care Guidelines for Residential Treatment Facilities for Children and Adolescents (" Level of Care Guidelines" ) which provide that:
In considering the appropriateness of any level of care, all basic elements of the medical necessity definition should be met:
Except where state law or regulation requires a different definition, " Medically Necessary" or " Medical Necessity" shall mean health care services that a Provider, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are
(a) in accordance with generally accepted standards of medical practice;
(b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and
(c) not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment
of that patient's illness, injury or disease.
The Level of Care Guidelines further provide that:
The goal of Residential treatment is for stabilization of those symptoms that led to the admission and to facilitate a successful transition back to the community. In addition residential treatment is a level of care where the expectation is that improvement to a substantially better level of functioning can occur through the active participation of the client in the recommended treatment. This is not identical to placement in a therapeutic group home, where the structure of the program manages behaviors without an expectation that the client actively cooperates with the recommended treatment. This level of care is not meant primarily for the purpose of maintenance of gains made earlier in treatment.
The Guidelines for Continued Stay at the residential level of care provide as follows:
(All of the following must be met)
1. The child/adolescent continues to meet all basic elements of medical necessity.
2. The child/adolescent (and family as appropriate) has participated in the development of an individualized treatment plan, which includes consideration of all applicable and appropriate treatment modalities, realistic and achievable treatment goals, and a discharge plan with specific timelines for expected implementation and completion. Despite active participation by the participant, the treatment plan implemented has not led to enough improvement in the child/adolescent's condition such that he/she cannot yet safely move to and sustain improvement in a less restrictive level of care as evidenced by:
o the child/adolescent continues to suffer from symptoms and/or behaviors that led to this admission; OR
o the child/adolescent has developed new symptoms and/or behaviors that require this intensity of service for safe and effective treatment; AND
o the facility is able to show that they are actively working to identify a comprehensive plan to support the child/adolescent's transition to a community setting.
3. The child/adolescent and family continue to participate in active weekly face-to-face (or an approved alternate schedule) family therapy. Multi[-]family group is not a substitute for individual family therapy.
The Discharge Guidelines at the Residential treatment level of care provide as follows:
(Must meet one of the following)
1. Continued stay guidelines are no longer met.
2. Appropriate and timely treatment is available at a less restrictive level of care.
3. The child/adolescent has developed symptoms that require a more intensive level of care.
4. The child/adolescent has developed symptoms of a secondary condition that require admission to an acute care medical facility.
B. D.H.'s Condition Prior to Residential Treatment
On April 10, 2012, Plaintiff called CBH regarding his interest in ...