- Acute lymphocytic leukemia following first or second relapse;
- Acute non-lymphocytic leukemia following first or second relapse.
As discussed in greater detail in Section IV, infra, it is not at all apparent that high dose chemotherapy is excluded from coverage simply because bone marrow transplantation is a necessary incident to the procedure. The plan does and continues to cover chemotherapy for breast cancer. The Blue Cross letter did not effectively give notice to the employer that an employee beneficiary undergoing chemotherapy treatment would be denied coverage simply because related bone marrow removal and transplantation is also necessary.
The ineffectiveness of the notice is most clearly evidenced by Blue Cross' ultimate amendment. That amendment, which took effect on January 1, 1992, clearly states that high dose chemotherapy treatment is excluded "when supported by transplant procedures." Blue Cross/Blue Shield 1992 Service Benefit Plan Brochure for the Federal Employee Program. The difference between the explicitness of the notice and the actual amendment underscores that the employer was not effectively advised of Blue Cross' prospective change.
Blue Cross' own citations emphasize the importance of the employer's decision in what benefits are to be conferred under its ERISA program. See, e.g., Nazay v. Miller, 949 F.2d 1323, 1328 (3d Cir. 1991); Moore v. Reynolds Metals Co. Retirement Program for Salaried Employees, 740 F.2d 454, 456 (6th Cir. 1984). Thus, where notice to the employer is not timely or effective, ERISA is violated because the employer is not able to make a voluntary and informed choice as to its benefits program.
Defendant's Fiduciary Duty and Conflict of Interest
Under ERISA the employer administers the benefits plan and, in the case of health insurance, adjudicates claims for coverage under the plan. The employer's role in that capacity is that of a fiduciary. See 29 U.S.C. § 1104. However, frequently the employer delegates responsibility for adjudication of claims to the insurance carrier, as indeed was the case here. With its assumption of the role of a claims adjudicator, the carrier also assumes the employer's role as fiduciary. See Brown v. Blue Cross & Blue Shield of Alabama, 898 F.2d 1556, 1561 (11th Cir. 1990).
The insurance carrier which both issues a policy and administers it occupies dual roles that create an inherent conflict of interest. See id. In its fiduciary role, the insurance company interprets the plan, determining what expenses are covered. This fiduciary, however, is the same company that will ultimately pay for those expenses from its own coffers. Thus, the insurance company's "fiduciary role lies in perpetual conflict with its profit-making role as a business."
Id. The inherent conflict between the fiduciary responsibilities of the insurance carrier and its own financial interests renders the insurance carrier's interpretation of the plan suspect and requires that the Court scrutinize the carrier's interpretation with great care to determine whether the carrier acted free of self-interest. See id. at 1566-68.
In this instance, Blue Cross has conceded that it acted out of self-interest. It has stated, as discussed supra, that because courts were ruling that the treatment at issue here was not "experimental" or "investigative," it could no longer deny coverage on that basis, and for that reason it sought to change the policy to achieve that goal. In other words, when Blue Cross, in its role as a fiduciary to plaintiff and others like her, was faced with having to pay for the treatment, it turned to take back the benefit in its capacity as the insurance carrier. This is a classic conflict of interest. See Restatement (Second) of Trusts § 187, comment d. Accordingly, the Blue Cross interpretation of the amendment is not entitled to deference.
Interpretation of the Amendment
The Blue Cross notice of the amendment to the plan stated that "services or supplies for or related to transplant procedures" are not covered except "autologous bone marrow for" the five diseases identified.
However, plaintiff did not seek a transplant as such. In her case and those of others like her, it is chemotherapy that is generally regarded as the most effective treatment for her cancer in its advanced stages. Accordingly, plaintiff sought high dose chemotherapy which will save her life, and to that chemotherapy a bone marrow transplant is a necessary incident.
There is no dispute that under all normal circumstances the health plan covers plaintiff's chemotherapy and any hospital stay. Blue Cross seeks to escape that undisputed and indisputable conclusion on the basis of the argument that plaintiff's chemotherapy treatment, and every other facet of her hospital stay and current treatment, are excluded from coverage because they are "related to" a bone marrow transplant.
Eighty to ninety percent of plaintiff's treatment involves chemotherapy. Thus to consider that her primary treatment and every other facet of her treatment and recovery are removed from coverage through the narrow siphon of the words "related to" is to contort both the facts and the language.
This is illustrated most dramatically by the circumstance that Blue Cross refuses to pay even for plaintiff's current recuperative stay in the hospital on the basis that it, too, is "related to" the transplant -- even though the transplant was effected in the past and is not to be repeated. Under these circumstances, to say that payment is excluded by virtue of the notion that the entire treatment, in all its facets, past, present, and future, is "related to" bone marrow transplantation would truly have the tail wagging the dog.
That interpretation proffered by Blue Cross is too clever by half.
In the context of a request for a preliminary injunction, the plaintiff need not demonstrate an absolute certainty of success on the merits. Washington Metropolitan Area Transit Commission, supra, 559 F.2d at 844. It is enough that she raises legal questions that are sufficiently serious and substantial that a more thorough investigation is appropriate. Population Institute v. McPherson, supra, 797 F.2d at 1078. This case is apparently one of first impression, and the Court concludes that it involves serious and substantial issues.
Plaintiff remains in the hospital where medical personnel can continue to combat her cancer, her recovery from the physical trauma of the treatment can be effected, and her depleted immune system can be bolstered. Particularly in the context of the balance of injuries, it cannot be sufficiently emphasized that plaintiff suffers from advanced breast cancer, and it was uncontradicted that without the chemotherapy treatment she would have died within months.
There is a narrow "window of time during which the treatment [can] be rendered." Dozsa v. Crum & Forster Ins. Co., 716 F. Supp. 131, 133 (D.N.J. 1989). At the time of the hearing on the temporary restraining order, before plaintiff began the treatment at issue here, she faced nearly certain death, the ultimate irreparable injury. Today the specter of injury has improved in degree only, not in kind: plaintiff's health and future remain in serious doubt.
Absent injunctive relief, Blue Cross would refuse to pay not only for the treatments already administered but for any treatment tomorrow and in the near future because, it contends, it is all "related to" the bone marrow transplant, and the consequences discussed above would follow. Plaintiff clearly has established irreparable injury.
Possibility of Substantial Injury to Defendant
By comparison, the injury to Blue Cross from the issuance of a preliminary injunction would be strictly financial. The estimated cost of the procedure at issue ranges from $ 75,000 to $ 100,000. Blue Cross is an insurance carrier which has surely anticipated such contingencies as are necessary when it must pay for services that it believed were excluded. The prospect of financial injury to Blue Cross in this instance cannot be deemed substantial.
The parties have treated the public interest prong as if it were a debate on health care: The rising costs of health care and insurance premiums on the one hand, and the dramatic prevalence of breast cancer on the other. In fact, the public interest in this case rests on the more mundane issue of ERISA. The legislative choices with regard to health policy are not before the Court, but the legislative direction that created ERISA is squarely before it.
The public interest in this case is served by ensuring that the notice requirements of ERISA are complied with, that employers are enabled to make timely and informed choices regarding the benefits they provide their employees, and that insurance plans are interpreted fairly, free of conflict, and in a manner that preserves rather than removes coverage. The Court concludes that the public interest is served by a preliminary injunction.
An Order consistent with this Opinion is issued contemporaneously herewith.
May 4, 1992
HAROLD H. GREENE
United States District Judge
ORDER - May 4, 1992, Filed
Upon consideration of the motion for a preliminary injunction, the opposition thereto, the hearing held May 1, 1992, and the entire record herein, it is this 4th day of May, 1992, in accordance with the Opinion issued herewith
ORDERED that plaintiff's motion for a preliminary injunction be and it is hereby granted; and it is further
ORDERED that defendant be and it is hereby enjoined from notifying Johns Hopkins Hospital that plaintiff is not insured for High Dose Chemotherapy with Autologous Bone Marrow Transplant (HDCT-ABMT); and it is further
ORDERED that defendant be and it is hereby enjoined from denying coverage for treatment for plaintiff's current illness but shall reimburse John Hopkins Hospital for such treatment; and it is further
ORDERED that this Order shall be valid until final disposition of this case on the merits.
HAROLD H. GREENE
United States District Judge