United States District Court, C.D. California, Southern Division
FINDINGS OF FACT AND CONCLUSIONS OF LAW
O. CARTER UNITED STATES DISTRICT JUDGE.
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.
FINDINGS OF FACT
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.
Plan is an employee welfare benefit plan regulated by the
Employee Retirement Income Security Act of 1974
Plaintiff's dependent son, Nicholas Potter
(“Potter”), is also a covered beneficiary under
the plan. Id.
Covered by Blue Shield
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
Potter was a resident at Innercept between January 17, 2012
and December 13, 2012. Id. Ex. 10 at Potter0523.
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.
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.
January 2012, Potter ran away from Innercept at least twice.
Pl. Op. Br. at 4.
January 26, 2012 drug screen tested positive for alcohol and
marijuana. Id. at 10; see Pl. Admin. Rec.
Ex. 8 at Potter0492.
February 1, 2012, Potter ran away from Innercept again. Pl.
Op. Br. at 5.
few days later, Potter was hospitalized at Kootenai
Behavioral Health. He was released by February 8, 2012.
Id.; BS Op. Br. at 7.
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.
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.
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.
early May 2012, Drs. Ullrich and Stoddard decreased
Potter's Zyprexa prescription and increased his lithium
prescription. BS Op. Br. at 11.
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.
May 29, 2012, Dr. Stoddard decreased Potter's Klonopin
prescription. Pl. Admin. Rec. Ex. 8 at Potter0469.
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.
June 5, 2012, Dr. Stoddard decreased Potter's Klonopin
prescription again. Id. Ex. 8 at Potter0467.
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.
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).
July 10, 2012, Dr. Stoddard entered an order for Potter to
discontinue Klonopin altogether. Pl. Admin. Rec. Ex. 8 at
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.
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.
September 5, 2012, Dr. Stoddard again decreased Potter's
Zyprexa prescription. Id. at Potter0490.
September 18, 2012, Dr. Stoddard again decreased Potter's
Zyprexa prescription. Id. at Potter0503.
Potter's September 30, 2012 drug screen was positive for
alcohol. Pl. Admin. Rec. Ex. 8 at Potter0491.
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.
November 4, 2012, Potter tested positive for alcohol and
illegal substances. Id. Ex. 8 at Potter0491.
Potter was discharged from Innercept on December 13, 2012.
Id. Ex. 6 at Potter0204.
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.
There is no record of Potter running away from Innercept
between July 1, 2012 and December 13, 2012.
Blue Shield has refused to cover Potter's treatment at
Innercept for the period between July 1, 2012 and December