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Doe v. Mamsi Life and Health Insurance Co.

January 25, 2007

JANE DOE, PLAINTIFF,
v.
MAMSI LIFE AND HEALTH INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: Ellen Segal Huvelle United States District Judge

MEMORANDUM OPINION

Plaintiff has brought suit under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq., challenging the denial of claims for health care benefits for inpatient and outpatient treatment of bulimia nervosa under a private employer-sponsored group welfare benefit plan. The parties agree that the plan is governed by ERISA, and that defendant MAMSI Life and Health Insurance Company ("MAMSI") administers the plan under which plaintiff received health benefits pursuant to 29 U.S.C. § 1002(16)(A). (Def. Facts ¶¶ 1-3; Def. Mot. at 1; Pl. Reply at 2.) The case is presently before the Court on the parties' cross-motions for summary judgment. For the reasons explained herein, the Court will deny defendant's motion in part and grant plaintiff's motion in part insofar as it remands the case to MAMSI for reconsideration of its denial of coverage for plaintiff's inpatient treatment. The Court, however, will deny plaintiff's motion in part insofar as it seeks reversal of MAMSI's decision regarding plaintiff's claim for coverage of her outpatient treatment.

BACKGROUND AND PROCEDURAL HISTORY

Plaintiff was admitted to River Oaks Hospital in New Orleans, Louisiana on October 13, 2004, for the treatment of bulimia nervosa. (A.R. 318.) At the time she was a 20-year-old college student enrolled at a Louisiana college. (A.R. 318, 324.) The administrative record indicates that plaintiff had a history of anxiety, panic attacks, and depression. (A.R. 326, 328.) Her binging and purging behavior apparently began in November 2003. (A.R. 582.) The record indicates that plaintiff had not experienced any suicidal ideation (A.R. 318, 328, 338), but she reported that at times, she had a strong urge to "do something shocking or harmful." (A.R. 328.) She also reported a history of "cutting" or self-mutilation while in the eleventh grade. (A.R. 326.) Plaintiff first sought psychiatric treatment for her eating disorder in the spring of 2004 with Dr. Henderson in New Orleans, and she continued treatment with Dr. Trippitelli in Washington, D.C. -- plaintiff's home city -- in the summer of 2004, before returning to New Orleans at the end of August for her junior year in college. (A.R. 324, 556, 578.) Both Drs. Henderson and Trippitelli prescribed the anti-depressant drug Prozac to plaintiff. (A.R. 556, 583.) She reported to Dr. Trippitelli that the Prozac improved her binging and purging behavior (A.R. 582), but plaintiff apparently discontinued the medication, and she was not taking any anti-depressant medications at the time of her admission to River Oaks. (A.R. 582, 326, 664.) Dr. Trippitelli also recommended that plaintiff seek inpatient or partial hospitalization treatment for her eating disorder in July 2004, but plaintiff resisted her suggestion at that time. (A.R. 324, 583.)

Plaintiff's binging and purging behavior continued after her return to school in New Orleans in the fall of 2004. (A.R. 318, 324, 327.) She reported binging and purging up to fourteen times per week in the two to three months leading up to her admission, and she also reported taking up to thirty-five diet pills per week. (A.R. 326-27.) Several weeks prior to her inpatient admission, plaintiff began outpatient treatment for bulimia with social worker Mary Stock at River Oaks and a nutritionist. (A.R. 318, 556.) Upon admission to River Oaks, plaintiff, who stands 5'2" tall, weighed 117 or 119.2 pounds. (A.R. 326, 357.) She reported that in the preceding year-and-a-half, her maximum weight was 135 pounds, and her minimum weight was 110 pounds. (A.R. 318, 357.) The record indicates that the River Oaks Staff considered the "[i]deal body weight" for plaintiff to be 110 pounds, plus or minus 10 percent. (A.R. 357.) Plaintiff remained as an inpatient at River Oaks, where she received extensive individual and group and family therapy, until November 8, 2004 (see generally A.R. 367-436), at which point she transitioned into River Oaks' Partial Hospitalization Program ("PHP"). The PHP program provided a similar level of therapy as the inpatient program, as well as supervised meals, but plaintiff slept at her own home each night. (See generally A.R. 602-54.) Her PHP treatment concluded on November 22, 2004. (A.R. 654.)

Plaintiff's doctors submitted two claims to MAMSI for the treatment she received at River Oaks during October and November of 2004. Initially, a River Oaks staff member made a telephone request for coverage for "acute inpatient psychiatric hospitalization" upon plaintiff's admission on October 13, 2004. (A.R. 1-2, 307-08.) By letter dated October 14, 2004, MAMSI denied plaintiff's first claim on the grounds that inpatient hospitalization was not "medically necessary" for the treatment of her medical condition. (A.R. 1-2.) Plaintiff's caregivers then submitted a subsequent claim for her PHP treatment on November 9, 2004. (A.R. 236, 776.) By letter dated November 10, 2004, MAMSI denied plaintiff's second claim, this time on the grounds that plaintiff had failed to obtain pre-certification, as required by the Group Certificate, prior to her admission for the PHP, which MAMSI considered to have been "non-emergent and elective."*fn1 (A.R. 236-40.) The Group Certificate notes that the insured must "seek and receive" pre-certification from MAMSI "before receiving certain non-Emergency outpatient Health Services . . . ." (A.R. 280.)

As the plan administrator, MAMSI is responsible for making benefit coverage decisions. MAMSI is also the provider of hospital and medical insurance benefits to plan enrollees and has agreed to provide such benefits in accordance with applicable plan documents. Most relevant for present purposes are the MAMSI Group Hospital and Insurance Policy Contract Face Sheet (the "Group Agreement") (Def. Facts Ex. A) and the MAMSI Group Certificate. (A.R. 271-301.) The Group Agreement provides that MAMSI "may adopt reasonable policies, procedures, rules and interpretations to promote orderly and efficient administration of this Contract, and Employer agrees to cooperate with [MAMSI] in administering such rules and regulations." (Def. Facts Ex. A at Article 9.3.) The Group Certificate, in turn, describes the coverage available to plan enrollees and the procedures required to obtain coverage. The plan "does not cover . . . Services that are not Medically Necessary." (A.R. 284.) As defined in the Group Certificate, "Medically Necessary" means Health Services which are reasonably necessary and in the exercise of good medical practice in accordance with professional standards accepted and commonly available in the United States for treatment of Sickness or Injury as determined by the Company. The service must 1) be appropriate and necessary for the symptom's diagnosis, or treatment of the medical condition; 2) be provided for the diagnosis or direct care or treatment of the condition; 3) not be provided for convenience; and 4) be performed or provided in the least costly setting or manner appropriate to diagnose or treat the Injury or Sickness. (A.R. 279 (emphasis added).)

I. Inpatient Care

In denying coverage for plaintiff's inpatient treatment as not medically necessary, MAMSI claims to have relied on its internal "Eating Disorder Care Criteria" ("the Criteria"). (Def. Facts ¶ 7.) The Criteria, which were approved in September 2003, provide that "acute inpatient" treatment for anorexia nervosa or bulimia nervosa is warranted when "[a]ny one of 2-4, or 1 and any one of 5-8" of the following conditions are met:

1. Weight Issues: Through determined food avoidance in the absence of any physical or mental illness, a refusal to maintain weight = or >75% of optimal body weight or approaching a weight at which physiological instability occurred in the past. For child/adol, may also be refusal to maintain bmi >15 or body weight <85% of="" optimal="" body="" weight="" during="" a="" period="" of="" rapid="" growth.="" (there="" are="" no="" particular="" weight="" indicators="" re:="" bulimia="">

2. Medical complications related to Eating Disorder: There are medical complications that require 24 hour skilled nursing care . . . .

3. Comorbid Biomedical issues: Diabetes, Pregnancy, Cardiovascular Disease, or any chronic medical illness that is worsening due to the patient's inability to manage eating disorder symptoms. Severity requires 24 hour monitoring by skilled nursing team.

4. Comorbid Psychiatric/Substance Abuse Issues: Psychiatric issues that meet inpatient acute psychiatric criteria. Substance Abuse Issues that meet inpatient rehab. ASAM criteria.

5. Readiness to Change/Engagement in Treatment: Resistant to acceptance of illness and treatment recommendations, or verbally agrees to participate, but requires 24 hour skilled nursing supervision to ...


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