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Potter v. Blue Shield of California Life and Health Insurance Co.

United States District Court, C.D. California, Southern Division

April 7, 2017

JOHN POTTER, Plaintiff,
v.
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY, Defendant.

          FINDINGS OF FACT AND CONCLUSIONS OF LAW

          DAVID O. CARTER UNITED STATES DISTRICT JUDGE.

         I. INTRODUCTION

         Following a bench trial in this matter, the Court issues the following findings of fact and conclusions of law pursuant to Federal Rule of Civil Procedure 52. To the extent that any findings of fact are included in the Conclusions of Law section, they shall be deemed findings of fact, and to the extent that any conclusions of law are included in the Findings of Fact section, they shall be deemed conclusions of law.

         II. FINDINGS OF FACT

         Background

         1. Plaintiff John Potter (“Plaintiff”) enrolled in Defendant Blue Shield of California Life and Health Insurance Company's (“Blue Shield” or “Defendant”) PPO 25 health plan (the “Plan”) through his employer, Hughes Investments. Plaintiff's Opening Brief (“Pl. Op. Br.”) (Dkt. 129) at 1.

         2. The Plan is an employee welfare benefit plan regulated by the Employee Retirement Income Security Act of 1974 (“ERISA”).

         3. Plaintiff's dependent son, Nicholas Potter (“Potter”), is also a covered beneficiary under the plan. Id.

         Period Covered by Blue Shield

         4. Potter was admitted to Innercept, LLC Residential Treatment for Adolescents and Young Adults (“Innercept”) on January 17, 2012. Motion to Determine the Administrative Record (“Pl. Admin. Rec.”) (Dkt. 121) Ex. 9 at Potter0516.

         5. Potter was a resident at Innercept between January 17, 2012 and December 13, 2012. Id. Ex. 10 at Potter0523.

         6. When he was admitted, Potter was taking Abilify (an antipsychotic medication used to treat depression and bipolar disorder), Zoloft (used to treat depression and stress disorders), and Protonix (used to treat gastroesophogeal disease). Id. Ex. 9 at Potter0519.

         7. While at Innercept, Potter was treated by psychiatrists Dr. Michael Ullrich and Dr. Tim Stoddard, and received therapy from social worker Rosa Mettler. Blue Shield's Opening Brief (“BS Op. Br.”) (Dkt. 117) at 5.

         8. In January 2012, Potter ran away from Innercept at least twice. Pl. Op. Br. at 4.

         9. A January 26, 2012 drug screen tested positive for alcohol and marijuana. Id. at 10; see Pl. Admin. Rec. Ex. 8 at Potter0492.

         10. On February 1, 2012, Potter ran away from Innercept again. Pl. Op. Br. at 5.

         11. A few days later, Potter was hospitalized at Kootenai Behavioral Health. He was released by February 8, 2012. Id.; BS Op. Br. at 7.

         12. Later in February, Potter and another resident had a physical altercation, which resulted in a call to the police. Pl. Admin. Rec. Ex. 9 at Potter0052 13. In early March 2012, Potter “eloped”-or ran away from-from Innercept again. BS Op. Br. at 8.

         14. On March 6, 2012, Dr. Ullrich prescribed lithium (used to treat bipolar disorder and depression) and Klonopin (used to treat panic disorder and anxiety) for Potter. Id. at 9.

         15. Altogether, Potter ran away from Innercept seven times during the first two months of treatment (i.e. in January through March of 2012). Id. at 19.

         16. In early May 2012, Drs. Ullrich and Stoddard decreased Potter's Zyprexa prescription and increased his lithium prescription. BS Op. Br. at 11.

         17. On May 17, 2012, Potter drank alcohol while away from the Innercept facility on a “pass.” Pl. Op. Br. at 6; BS Op. Br. at 12; Pl. Admin. Rec. Ex. 6 at Potter0321.

         18. On May 29, 2012, Dr. Stoddard decreased Potter's Klonopin prescription. Pl. Admin. Rec. Ex. 8 at Potter0469.

         19. Therapist logs from May 30, 2012 state that Potter relapsed two weeks before the log entry (i.e. sometime around May 16, 2012), specifically indicating that Potter smoked cigarettes. Id. Ex. 6 at Potter0314.

         20. On June 5, 2012, Dr. Stoddard decreased Potter's Klonopin prescription again. Id. Ex. 8 at Potter0467.

         21. On June 7, 2012, Potter ran away from Innercept again. He was not in contact with Innercept or his family until the next day. Pl. Op. Br. at 7. Potter's elopement lasted about five days, and he returned to Innercept on June 13, 2012. Id.; BS Op. Br. at 13- 14.

         22. Blue Shield has covered Potter's treatment for the period described above-specifically, January 17, 2012 to June 30, 2012. Defendant's Administrative Record Ex. D (Dkt. 132-6) (remand decision).

         Period in Dispute

         23. On July 10, 2012, Dr. Stoddard entered an order for Potter to discontinue Klonopin altogether. Pl. Admin. Rec. Ex. 8 at Potter0511.

         24. On July 25, 2012, Potter was moved from the Stabilization Program to the Transition Program following a successful overnight visit with his family. Pl. Op. Br. at 7.

         25. On August 7, 2012, Dr. Stoddard decreased Potter's Zyprexa prescription again (as described above, Potter's Zyprexa prescription was decreased in early May 2012). Pl. Admin. Rec. Ex. 8 at Potter0507.

         26. On September 5, 2012, Dr. Stoddard again decreased Potter's Zyprexa prescription. Id. at Potter0490.

         27. On September 18, 2012, Dr. Stoddard again decreased Potter's Zyprexa prescription. Id. at Potter0503.

         28. Potter's September 30, 2012 drug screen was positive for alcohol. Pl. Admin. Rec. Ex. 8 at Potter0491.

         29. On October 4, 2012, Potter was told that he tested positive for alcohol. When given the news, he became verbally aggressive. Id. Ex. 6 at Potter0244.

         30. On November 4, 2012, Potter tested positive for alcohol and illegal substances. Id. Ex. 8 at Potter0491.

         31. Potter was discharged from Innercept on December 13, 2012. Id. Ex. 6 at Potter0204.

         32. Upon discharge, Innercept recorded Potter's diagnoses as: (1) Bipolar Disorder Type II, (2) Anxiety Disorder, (3) Polysubstance Dependence, and (4) Attention Deficient/Hyperactivity Disorder Predominantly Inattentive Type. Id. Ex. 10 at Potter0523.

         33. There is no record of Potter running away from Innercept between July 1, 2012 and December 13, 2012.

         34. Blue Shield has refused to cover Potter's treatment at Innercept for the period between July 1, 2012 and December 13, 2012.

         III. ...


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