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Jennifer A v. United Healthcare Insurance Company

September 11, 2012

JENNIFER A., PLAINTIFF,
v.
UNITED HEALTHCARE INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: Dale S. Fischer United States District Judge

FINDINGS OF FACT AND CONCLUSIONS OF LAW AFTER COURT TRIAL ON ADMINISTRATIVE RECORD

INTRODUCTION

This action is brought pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA") (29 U.S.C. § 1001, et seq.). Plaintiff Jennifer A. contends she is entitled to coverage for residential mental health treatment at the Montenido Treatment Center*fn1 beyond January 11, 2011 under the terms of the Azoff Promotions, Inc. employee benefit plan (the "Plan"). After consideration of the parties' trial briefs, oral arguments, the evidence in the Administrative Record,*fn2 and the extrinsic evidence offered by Plaintiff on the issue of the alleged conflict of interest of United Behavioral Health ("UBH"),*fn3 the Court makes the following Findings of Fact and Conclusions of Law.

FINDINGS OF FACT

It is undisputed that: (1) Plaintiff was a covered participant in the Plan, (2) the Plan was insured by United Healthcare Insurance Company ("UHIC") and governed by the UnitedHealthcare Choice Plus Policy (the "Policy")*fn4 , and (3) UHIC fully delegated claims administration authority for mental health services under the Plan to UBH. The Plan requires UHIC to pay benefits for Covered Health Services. (UHIC008.) Under the Plan, UHIC had discretionary authority to administer claims and make factual findings regarding benefits and covered services or to delegate such authority. (Id.) The Plan unambiguously grants UHIC the right to delegate this discretionary authority "to other persons or entities that may provide administrative services for this Benefit plan, such as claims processing." (UHIC008.) It is undisputed that UHIC fully delegated its discretionary claims administration authority for mental health and substance abuse benefits to non-party UBH through an Administrative Services Agreement ("ASA") dated January 1, 2006. (Decl. of Cheryl F. Knoblauch Ex. B. at UHIC344-49.)

The Plan provides in part:

Covered Health Service(s) - those health services, including services, supplies, or Pharmaceutical Products, which we determine to be all of the following:

* Provided for the purpose of preventing, diagnosing or treating a Sickness, Injury, Mental Illness, substance abuse, or their symptoms.

* Consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines as described below.

* Not provided for the convenience of the Covered Person, Physician, facility or any other person.

* Described in this Certificate of Coverage under Section 2: Exclusions and Limitations.

In applying the above definition, "scientific evidence" and "prevailing medical standards" shall have the following meanings:

* "Scientific evidence" means the results of controlled clinical trials or other studies published in peer-reviewed, medical literature generally recognized by the relevant medical specialty community.

* "Prevailing medical standards and clinical guidelines" means nationally recognized professional standards of care including, but not limited to, national consensus statements, nationally recognized clinical guidelines, and national specialty society guidelines.

We maintain clinical protocols that describe the scientific evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding specific services. These clinical protocols (as revised from time to time), are available to Covered Persons on www.myuhc.com or by calling Customer Care at the telephone number on your ID card, and to Physicians and other health care professionals on UnitedHealthcareOnline. (UHIC061.)

Section 1: Covered Health Services

16. Mental Health and Substance Abuse Services - Inpatient and Intermediate Mental Health and Substance Abuse Services received on an inpatient or intermediate care basis in a Hospital or an Alternate Facility . . . . The Mental Health/Substance Abuse Designee, who will authorize the services, will determine the appropriate setting for the treatment . . . . Mental Health . . . Services must be provided by or under the direction of the Mental Health/Substance Abuse Designee. Referrals to a Mental Health or Substance Abuse Services provider are at the discretion of the Mental Health/Substance Abuse Designee, who is responsible for coordinating all of your care . . . . (UHIC016-017.)

Section 2: Exclusions and Limitations

H. Mental Health/Substance Abuse

2. Mental Health Services . . . that extend beyond the period necessary for short-term evaluation, diagnosis, treatment or crisis intervention . . . .

8. Services or supplies for the diagnosis or treatment of Mental Illness . . . that, in the reasonable judgment of the Mental Health/Substance Abuse Designee, are any of the following:

* Not consistent with prevailing national standards of clinical practice for the treatment of such conditions.

* Not consistent with prevailing professional research demonstrating that the services or supplies with have a measurable and beneficial health outcome.

* Typically do not result in outcomes demonstrably better than other available treatment alternatives that are less intensive or more cost effective.

* Not consistent with the Mental Health/Substance Abuse Designee's level of care guidelines or best practices ...


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