United States District Court, W.D. North Carolina, Charlotte Division
L.B., A MINOR, BY AND THROUGH HER GUARDIAN ANN BROCK, Plaintiff,
UNITED BEHAVIORAL HEALTH, INC., WELLS FARGO & COMPANY HEALTH PLAN, Defendants
[Copyrighted Material Omitted]
For Ann Brock, as lawful guardian ad litem of Minor Child, L. B., Plaintiff: Bryan Lee Tyson, Marcellino & Tyson, PLLC, Charlotte, NC.
For Wells Fargo & Company Health Plan, Defendant: Nathan Douglas Childs, LEAD ATTORNEY, Robinson & Lawing, LLP, Winston-Salem, NC.
For United Behavioral Health, Inc., Defendant: Howard Brent Helms, Nathan Douglas Childs, LEAD ATTORNEYS, Robinson & Lawing, LLP, Winston-Salem, NC.
Max O. Cogburn Jr., United States District Judge.
THIS MATTER is before the court on cross motions for summary judgment. After fully briefing the issues, the court heard oral arguments during a bench trial of this matter.
Defendants contend that the final decision of the plan administrator denying plaintiff's claim for benefits at an out-of-state, acute in-patient psychiatric care facility should be affirmed as reasonable. Plaintiff contends that the plan administrator (" UBH" ) abused its discretion in denying her claim for in-patient care her daughter, " L.B.,"  received at the Menninger Clinic (" Menninger" ) were medically necessary as evidenced by the opinions of her treatment team at the Levine Children's Hospital (" Levine" ) in Charlotte as well as UBH's own Level of Care Guidelines. Plaintiff contends that immediately prior to presenting at Menninger, L.B. twice attempted suicide; that the second attempt was serious at it resulted in hospitalization at Levine and caused her to suffer a seizure; and that her team at Levine refused to release her to go home as she presented a danger to herself, releasing L.B. only to go directly to Menninger, where a bed was available.
Earlier in this litigation, the court remanded the final decision to UBH to consider documents plaintiff contends were not previously considered. The court later modified that order to allow plaintiff to submit any materials she desired to present to the plan administrator. Upon remand, the plan administrator again denied benefits, a decision which was in turn reviewed by an independent review organization (" IRO" ) in accordance with the Affordable Care Act.
" The Employee Retirement Income Security Act of 1974" (" ERISA" ) allows plan participants or beneficiaries who are denied benefits under an employee benefit plan to challenge the plan administrator's denial in federal court. Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008). Unlike claims made on over-the-counter insurance plans that a consumer may acquire in the marketplace,
ERISA imposes higher-than-marketplace quality standards on insurers. It sets forth a special standard of care upon a plan administrator, namely, that the administrator 'discharge [its] duties' in respect to discretionary claims processing 'solely in the interests of the participants and beneficiaries' of the plan; it simultaneously underscores the particular importance of accurate claims processing by insisting that administrators provide a 'full and fair review' of claim denials, and it supplements marketplace and regulatory controls with
judicial review of individual claim denials.
Id. at 115 (citations omitted). In the Fourth Circuit, a district court reviewing the final decision of a plan administrator
must be guided by principles of trust law, taking a plan administrator's determination as 'a fiduciary act (i.e., an act in which the administrator owes a special duty of loyalty to the plan beneficiaries).' Second, courts must 'review a denial of plan benefits under a de novo standard unless the plan provides to the contrary.' Third, when the plan grants the administrator 'discretionary authority to determine eligibility for benefits ... a deferential standard of review is appropriate.' And fourth, '[i]f a benefit plan gives discretion to an administrator or fiduciary who is operating under a conflict of interest, that conflict must be weighed as a factor in determining whether there is an abuse of discretion.'
Champion v. Black & Decker (U.S.), Inc., 550 F.3d 353, 358 (4th Cir.2008) (citation omitted).
The Wells Fargo & Company Health Plan (" Plan" ) gives the Plan Administrator UBH discretion in deciding questions of eligibility for benefits; thus, this court reviews such determinations for an abuse of discretion. See Williams v. Metropolitan Life Ins. Co., 609 F.3d 622, 629-30 (4th Cir. 2010). Under the abuse of discretion standard, a trial court will not disturb a plan administrator's decision if it is " reasonable." Id. at 630.
A decision is " reasonable" if it: (1) results from a deliberate, principled reasoning process; and (2) is supported by " substantial evidence." Id. In turn, substantial evidence is evidence which a reasoning mind would accept as sufficient to support a particular conclusion. DuPerry v. Life Ins. Co. of North Am., 632 F.3d 860, 869 (4th Cir. 2011). In determining reasonableness, the Court of Appeals for the Fourth Circuit has held that courts should look to several factors, including: (1) the language of the plan; (2) the purposes and goals of the plan; (3) the adequacy of the materials considered to make the decision and the degree to which they support it; (4) whether the fiduciary's interpretation was consistent with other provisions in the plan and with earlier interpretations of the plan; (5) whether the decision-making process was reasoned and principled; (6) whether the decision was consistent with the procedural and substantive requirements of ERISA; (7) any external standard relevant to the exercise of discretion; and (8) the fiduciary's motive and any conflict of interest it may have.
Williams, 609 F.3d at 630.
Finally, this court's review is limited to the record that was before the plan administrator at the time of final determination. Sheppard & Enoch Pratt Hosp., Inc. v. Travelers Ins. Co., 32 F.3d 120, 125 (4th Cir. 1994) (" [A]n assessment of the reasonableness of the administrator's decision must be based on the facts known to it at the time." ). In accordance with Sheppard & Enoch, the court granted defendants' Motion in Limine to exclude live testimony at the hearing from L.B.'s physician and her mother.
With such framework in place, the court has carefully considered the cross motions for summary judgment. Where cross motions for summary judgment are filed, such motions are
no more than a claim by each side that it alone is entitled to summary judgment, and the making of ...