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Suzanna Mcmahan v. United Healthcare Insurance Company

September 13, 2012

SUZANNA MCMAHAN,
PLAINTIFF,
v.
UNITED HEALTHCARE INSURANCE COMPANY, ET AL.,
DEFENDANTS.



The opinion of the court was delivered by: M. James Lorenz United States District Court Judge

ORDER GRANTING DEFENDANTS' MOTION FOR SUMMARY JUDGMENT [DOC. 16]

On January 12, 2011, Plaintiff Suzanna McMahan commenced this action against Defendants United Healthcare Insurance Company ("UHC") and Farmers Group, Inc. Medical Plan ("Farmers") seeking declaratory judgment and injunctive relief under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1132(a), (e), (f), and (g). This action arises from UHC's decision to deny Plaintiff's request for health benefits (obesity surgery). Defendants now move for summary judgment. (Doc. 16.) Plaintiff opposes.

The Court found this motion suitable for determination on the papers submitted and without oral argument. See Civ. L.R. 7.1(d.1). (Doc. 23.) For the following reasons, the Court GRANTS Defendants' motion for summary judgment.

BACKGROUND*fn1

A. The Summary Plan Description ("SPD")

Plaintiff is an employee of Farmers Insurance Exchange, and in 2010, she was a participant in Farmers' Welfare Benefit Plan ("Plan"), an employee welfare benefit plan regulated by ERISA. (JSUF ¶¶ 1--2.) The Plan is self-funded by Farmers. (Id. ¶ 3.)

The SPD,*fn2 effective January 1, 2010, designates Farmers as both the Plan Administrator and Plan Sponsor, and UHC as the Claims Administrator. (SPD 1, 93, 100; JSUF ¶¶ 3--4.) It states that Farmers and UHC have the "sole and exclusive discretion" to: (1) "interpret Benefits under the Plan"; (2) "interpret the other terms, conditions, limitations and exclusions of the Plan, including this SPD and any Riders and/or Amendments"; and (3) "make factual determinations related to the Plan and its Benefits." (SPD 88.) Farmers and UHC may also "delegate this discretionary authority to other persons or entities that provide services in regard to the administration of the Plan." (Id.)

Section 6 of the SPD provides Additional Coverage Details, supplementing the Plan Highlights contained in Section 5. (SPD 22.) This section includes covered health services for which the Plan pays Benefits, and covered health services that require the participant to notify Personal Health Support before receiving them as well as any reduction in Benefits that may apply. (Id.) One of the covered health services listed under Section 6 is Obesity Surgery. (Id. at 33.) "The Plan covers surgical treatment of obesity provided by or under the direction of a Physician when all of the following are true:

# you have a minimum Body Mass Index (BMI) of 40; or # you have documentation from a Physician of a diagnosis of morbid obesity for a minimum of five years; # you are over the age of 21; and # the surgery is performed at a Network Hospital by a Network surgeon even if there are no Network Hospitals near you." (SPD 33.)

Section 9 of the SPD sets forth the Claims Procedures, including the options available to plan participants following the denial of a claim and procedures to file a formal appeal. (SPD 62--68.) The SPD gives participants the option to call UHC following the denial of a claim before requesting a formal appeal. (Id. at 64.) If a participant wishes to appeal a denied pre-service request for Benefits or post-service claim, then the participant is instructed to submit an appeal in writing to UHC. (Id.) UHC then conducts a "full and fair review" of the appeal. (Id. at 65.) If unsatisfied with the first-level-appeal decision, the participant "[has] the right to request a second level appeal from UnitedHealthcare." (Id.) "UnitedHealthcare's decision will be final." (Id.) Under Section 9, UHC is responsible for assessing requests for Benefits and rendering decisions for all levels of appeal. (Id. at 65--68.)

B. Plaintiff's Request for Pre-Approval of Obesity Surgery

On June 24, 2010, Plaintiff requested pre-approval for obesity surgery from UHC. (JSUF ¶ 5.) On July 7, 2010, UHC denied the request on the grounds that Plaintiff failed to meet all four of the criteria listed for coverage for the surgery. (Id. ¶ 7; Wojcik Decl. Ex. C.) Specifically, UHC found that Plaintiff did not have documentation from a physician of a diagnosis of morbid obesity for a minimum of five years. (Wojcik Decl. Ex. C.) UHC based its denial on the following language in the SPD:

The Plan covers surgical treatment of obesity provided by or under the direction of a Physician when all of the following are true: you have a minimum Body Mass Index (BMI) of 40; or you have documentation from a Physician of a diagnosis of morbid obesity for a minimum of five years; you are over the age of 21; and the surgery is performed at a Network Hospital by a Network surgeon even if there are no Network Hospitals near you. (Wojcik Decl. Ex. C.)

After UHC denied her request, Plaintiff formally appealed. On August 10, 2010, Plaintiff submitted a first-level appeal to UHC. (JSUF ¶ 9.) She argued that the obesity surgery should be covered because she had a BMI over 40, and thus, she met the SPD's first requirement for surgery pre-approval. (Wojcik Decl. Ex. D.) However, on August 27, 2010, UHC upheld the denial of benefits for obesity surgery on the grounds that Plaintiff failed to meet Criterion 2-"Documentation from a Physician of a diagnosis of morbid obesity for a minimum of five years"-for obesity surgery. (Wojcik Decl. Ex. E.) Dr. Stephen Lincoln, M.D. reviewed the appeal, and reached that conclusion after reviewing additional clinical information. (Id.)

On October 18, 2010, Plaintiff submitted a second-level appeal to UHC. (JSUF ¶ 13.) Plaintiff again contended that the SPD requires that only one of the first two criteria need to be satisfied to qualify for bariatric (obesity) surgery. (Wojcik Decl. Ex. F.) She also explained that a UHC Customer Service Representative advised her that "it was clear [she] qualified for the surgery based on the language and stated that [the request] had been denied by mistake." (Id.) That representative later contacted Plaintiff and stated that the policy was "written incorrectly," should have stated "and" after Criterion 2, and that the company was in the process of trying to have the language changed. (Id.) Plaintiff also stated in her second-level appeal that she spoke with a UHC Customer Service Supervisor, Customer Service Manager, and Business Manager.

.) All three representatives acknowledged to her that the policy "clearly shows" the word "or," and that, at the time, UHC was "in the process of changing the language." (Id.)

Eventually, UHC once again upheld its denial of Plaintiff's request for pre-approval for obesity surgery. (JSUF ΒΆ 15.) On November 5, 2010, UHC sent Plaintiff a letter explaining that her request for obesity surgery is not a covered benefit because, "based upon the clinical information provided for this review, the specific requirement for [] Documentation from a Physician of a diagnosis of morbid obesity for a minimum of five years has not been met." (Wojcik Decl. Ex. G.) The letter also noted that there is a "typographic error in the Benefit Plan document of which Farmer's [sic] is aware" and "[t]he ...


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