United States District Court, D. Columbia
November 4, 2005.
HANNAH KLEIN, Plaintiff,
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT, Defendant.
The opinion of the court was delivered by: ROYCE LAMBERTH, District Judge
This matter comes before the Court on defendant United States
Office of Personnel Management's ("OPM") Motion  for Summary
Judgment pursuant to Rule 56(b) of the Federal Rules of Civil
Procedure. Plaintiff Hannah Klein brought suit on December 30,
2004, seeking payment for medical benefits under the Federal
Employees Heath Benefit Act ("FEHBA"), 5 U.S.C. § 8901 (2000).
OPM argues that the denial of benefits was proper becauses the
testing, diagnosis and treatment were medically unnecessary.
Also, OPM states that the denial of benefits should be affirmed
as administrative decisions are entitled to deference pursuant to
the Administrative Procedure Act ("APA"), 5 U.S.C. § 706(2)(A).
Upon consideration of defendant's motion, memorandum in support
thereof, opposition thereto and the entire record herein, the
Court shall grant OPM's Motion  for Summary Judgment.
Ms. Klein is a federal employee who was enrolled in and covered
by the Mail Handlers Benefit Plan ("Plan")) under a procurement
contract between OPM and the National Postal Mail Handlers Union. (Compl. 2.) From July 2001 through November 2002,
Ms. Klein received services at Woodlands Healing Research Center
("Provider") for a diagnosis of Allergic Rhinitis, Asthma, and
Irritable Bowel Syndrome ("IBS"). (Def.'s Mem. Supp. Summ. J. 6.)
Testing consisted of subcutaneous injections of food antigens.
(Id.) In December 2002, Ms. Klein and her Provider submitted
claims to the Plan seeking payment for the medical examinations,
allergy testing, and injectable antigens. (Compl. 2.) The Plan
first denied the claim for benefits in January 2003 reasoning
that the services billed did not appear to be necessary to treat
the listed diagnoses. (Def.'s Ex. A.) The Provider then submitted
a revised claim to the Plan who reviewed the claim once more.
(Id.) The Plan requested copies of medical records, doctors'
notes, treatment plans, results of testing and any other
documentation to determine whether benefits were available.
(Id.) On December 19, 2003, the Plan notified Ms. Klein that
her claim was being denied as not medically necessary. (Def.'s
Mem. 6.) Ms. Klein appealed the denial to OPM on March 16, 2004.
(Id.) After an independent medical review, OPM notified Ms.
Klein on May 24, 2004, that the denial was affirmed and informed
her of her right to bring suit in federal district court. (Id.)
On December 20, 2004, Ms. Klein filed the present complaint.
Summary judgment is appropriate when "the pleadings,
depositions, answers to interrogatories, and admissions on file,
together with the affidavits, if any, show that there is no
genuine issue as to any material fact and that the moving party
is entitled to a judgment as a matter of law." Fed.R.Civ.P.
56(c); see also Celotex Corp. v. Catrett, 477 U.S. 317, 322
(1986). To determine which facts are material, a court must look
to the substantive law on which each claim rests. Anderson v.
Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). A genuine issue
is one whose resolution could establish an element of a claim or
defense and consequently affect the outcome of the action.
Celotex, 477 U.S. at 322.
In ruling on a motion for summary judgment, the Court must draw
all justifiable inferences in the nonmoving party's favor and
accept the nonmoving party's evidence as true. Liberty Lobby,
477 U.S. at 255. If summary judgment is denied, there must be
evidence on which the jury could reasonably find for the
non-moving party. Id. at 252. A nonmoving party must establish
more than a "mere existence of a scintilla of evidence" in
support of its position. Id. Furthermore, if the non-moving
party "fails to make a showing sufficient to establish the
existence of an element essential to that party's case, and on
which that party will bear the burden of proof at trial," summary
judgment may be granted. Celotex, 477 U.S. at 322.
Pursuant to Liberty Lobby, the burden of proof for summary
judgment mirrors the substantive evidentiary standard that would
apply at trial. 477 U.S. at 254. Since this is a review of an
administrative agency's interpretation of a rule and is governed
by the APA, § 706(2)(A) mandates that the standard of review is
whether the decision was "arbitrary, capricious, an abuse of
discretion, or otherwise not in accordance with law."
Accordingly, when determining if a genuine issue of fact
regarding the denial of benefits exists, the Court must bear in
"mind the actual quantum and quality of proof necessary to
support liability" under the APA. Liberty Lobby,
477 U.S. at 254.
To determine whether an agency has acted in an arbitrary or
capricious fashion, a reviewing court must consider whether the
agency decision "was based upon a consideration of the relevant
factors and whether there has been a clear error in judgment."
Citizens to Preserve Overton Park, Inc. v. Volpe, 401 U.S. 402,
416 (1971). While the court must carefully scrutinize the facts material to a particular decision, "the ultimate
standard of review is a narrow one." Id.; see Bowman Transp.
Inc. v. Arkansas-Best Freight Sys., Inc., 419 U.S. 281, 285-86
As a preliminary matter, there is no genuine issue of material
fact here. In her Response, Ms. Klein disputes only a single
factual allegation. Ms. Klein submits an article discussing that
there may be a link between IBS and food allergens, thus making
the testing and treatment appropriate. (Pl.'s Resp. Ex. A.)
However, the article discussing the link is inconclusive. In
fact, the article recognizes that the link is far from a medical
certainty and only raises the specter of an indication of such a
link. (Id.) Given the attenuated nature of the link and the
deference owed to administrative interpretations of regulations,
the Court finds that there is no genuine issue of material fact
on this issue. Furthermore, since Ms. Klein did not submit any
affidavits, declarations or documentary evidence contradicting
all other factual assertions supporting OPM's Motion, the Court
accepts as true OPM's factual allegations.
Ms. Klein has not met her burden of showing that the decision
was arbitrary and capricious. OPM denied the claim because the
services were not medically necessary. Specifically, OPM argues
that the services were not appropriate to diagnose or treat Ms.
Klien's condition, illness, or injury and were inconsistent with
standards of good medical practice in the United States. The
finding that the diagnosis and treatment were inappropriate was
based on relevant factors and was not clear error. First, the
relationship between IBS and food allergies is tenuous at best.
(Def.'s Ex. G.) Denial of a benefits claim for services rendered
to treat a diagnosis which rests upon flimsy medical evidence is
not an arbitrary or capricious decision. Second, OPM found that
the services rendered were not medically necessary because WHRC
did not provide records indicating that Ms. Klein showed common
symptoms of food allergies, i.e., "chronic diarrhea, weight loss, malabsorption, rashes, angioedema
or episodes of anaphylaxis." (Id.) Without proper documentation
of the diagnosis for allergies, OPM could not conclude that the
testing and treatment was appropriate for the diagnosis.
OPM's denial of the benefits since the services rendered were
not consistent with standards of accepted medical practice in the
United States, was not arbitrary or capricious. OPM found that
the allergy evaluation was inappropriate. (Id.)
"An appropriate medical evaluation for allergies
includes a detailed physician-generated history of
specific food and seasonal antigen exposures.
Screening tests such as nasal smear of eosinophils
and IgE level may be performed. Limited standard
prick and intradermal testing may be performed when
warranted by correlation of history, physical
findings, and positive results of screening tests."
OPM concluded that WHRC did not follow standard medical practice
in diagnosing the allergen. Additional, OPM found that the
testing that did occur was inconsistent with standards of
appropriate medical practice. OPM found that the
provocation/neutralization testing is unproven and lacks
scientific validity. (Id.)
In light of the uncertainty of the link between IBS and food
allergies, the lack of proper testing, questions raised regarding
the validity and appropriateness of the testing employed, and the
deference owed to an agency's determination, the Court concludes
that OPM's denial of the benefits was based on relevant factors,
was not clear error and thus was not arbitrary or capricious.
For the foregoing reasons, Defendant's Motion for Summary
Judgment shall be granted. A separate Order shall issue this date.
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