NO T F O R P UBLI CATI O N

UNI T E D S T A T E S COURT OF A P P E A L S

F OR T H E NI NT H CI RCUI T

T ODD R. ; S UZ A

NNE R. ; L I L L I A

N R.
, F K A Jon
,

P l ai n

ti f f s

- A ppel l ees ,

v

.

P RE M E RA B L

UE CROS S B L

UE S H I E L D OF A L A S K

A
,

Def en dan t- A p pel l an t. No. 19- 35475

D. C. No. 2: 17- cv

- 01041- J L R

M E M O RA

NDUM *

A ppeal f r om th e Un i ted S tates Di s tr i ct Cou r t f or th e Wes t er

n Di str i ct of Was h i n g ton Jam es L

. Robar

t, Di s t r i ct J u dg e, P r es i di n g

A r g u ed an d S u

bm i tted J u l y 8, 2020 S eattl e, Was h i n g ton

B ef or e: CL I F T ON, D. M

. F I S H E R, * * an d M. S M I T H
, Ci r cu i t J u dg es

.

Def en dan t

- A ppel l an t P r em er a B l u e Cr o s s B l u e S h i el d of A l as ka appeal s th e

di s tr i ct cou

r t’ s ju dg m en

t i n an acti on br ou g h

t b y P l ai n ti f f s

- A ppel l ees T odd R.
, 

# FI L E D

S E P 1 2020

M O LLY C. DW Y E R, CLERK U. S. COURT OF APPEAL S

* T h i s di s pos i ti on

i s n ot appr opr i ate f

o r p u bl i cati on an d i s n o t pr eceden t

ex cept as pr ov i ded by Ni n th Ci r cu i t Ru l e 36- 3.

* * T h e H on or abl e D. M i ch ael F i s h er , Un i ted S tates Ci r cu i t J u dg e f or th e U. S

. Cou r t of A ppeal s f or th e T h i r d Ci r cu i t, s i tti n g b y des i g n ati on

.S u zan

n e R.
, an d L i l l i an R. to r ecov er m edi cal ben ef

i t s u n der an em

pl oy ee wel f

ar e

ben ef i ts pl an ( P l an ) s u

bject to th e E m

p l oy ee Reti r em en

t I n com e S ecu

r i t y A ct. We

v acate an d r em an d.

A l th ou g h we do n ot bel i ev e t h e di s tr i ct cou

r t i s i n a b etter pos i ti on th an

ou r s el v es to r ev i ew th e wr i tten adm i n i s tr ati v e r ecor d

, we n eed n ot r es ol v e t h e

par t i es ’ di s ag r eem en

t as to ou r s tan dar d of r ev i ew. E v en u n der a def er en ti al

s tan dar d, th e deci si on o n th e m er i ts was cl ear l y er r on eou s , s ee Silver

v. E xec. Car

L eas ing L ong- T

er m Dis ability P lan

, 466 F .3d 727, 732- 33 ( 9th Ci r

. 2006)

, an d th e

di s tr i ct cou

r t’ s depar tu r e f r o m t h e pr i n ci pl e of par

ty pr es en tati o n was an abu s e of

di s cr eti o n , s ee United States v. Sineneng- Smith

, 140 S

. Ct. 1575, 1578 ( 2020)

.

P l ai n ti f f s s eek r ei m

bu r s em en t of t h ei r p ay m en ts to E l ev ati o n s Res i den

ti al

T r eatm en t Cen ter , a f aci l i ty i n U tah

, f

or L i l l i an ’ s ar ou

n d- th e- cl ock beh av i or al

h eal th car e f

r om M ay 1, 2 014 t o J u

n e 21, 2 015. P r em er a, t

h e P l an adm

i n i s tr ator ,

den i ed cov er ag e f

or l ack of m

edi cal n eces si ty , f

i n di n g t h at L i l l i an s h owed n on e of

th e si x r i s k f

actor s u n d er th e “ Res i den

ti al A cu te B eh av i or al L ev el of Car e, Ch i l d or

A dol es cen

t” pol i cy ( Medi cal P ol i cy ) d

u r i n g th e cov er ag e per i od. T h at

deter m i n ati on was af

f i r m ed at each

l ev el of adm

i n i s tr ati v e r ev i ew. O n de n ov o

r ev i ew, t h e di s t r i ct cou r t di s ag r eed, f

i n di n g L i l l i an ’ s tr eatm en

t m edi cal l y

n eces s ar y

bas ed on th e M edi cal P ol i cy ’ s s i x th f actor : “ P ati en

t h as cu r r en t l y s tabi l i zed du

r i n g

2i n

pati en t tr eatm en t s tay f or s ev er e s y

m ptom s o r b eh av i or an d r equ i r es a s tr u ctu r ed

s etti n g wi th con t i n u ed ar ou n d- t h e- cl ock beh av i or al car e. ”

T h e di s tr i ct cou

r t cr af ted th at th eor

y s u a spon te. A t n o poi n

t bel o w h ad

P l ai n ti f f s ar g u ed, o r ev en “ so m

u ch as h i n t[ ed]

, ” Sineneng- Smith

, 140 S

. Ct. at

1580, t h at an y M edi cal P ol i cy f

actor s h ad b een sati sf

i ed. Rath er , th

r ou g h ou t th e

adm i n i s tr ati v e r ev i ew pr oces s , an d i n th ei r pl eadi n g s an d m

ov i n g paper s bef

or e th e

di s tr i ct cou

r t, P l ai n ti f f s adv o cated f

or th e u s e o f l es s d em an di n g g u i del i n es to

as s es s m edi cal n eces s i ty

. E v en af ter th e di s tr i ct cou

r t i ss u ed a s ch edu l i n g or der

i n s tr u cti n g th e par ti es to addr es s th e M edi cal P ol i cy ’ s s i x th f actor at th ei r h ear i n g ,

P l ai n ti f f s s ti l l d i d n ot adv an ce th e th eor y on wh i ch th e d i s tr i ct cou r t r el i ed.

On appeal

, P r em er a con

tes ts th e f i n di n g th at th e si x th pr ov i s i on appl i ed to

L i l l i an ’ s ci r cu

m s tan ces by ch al l en g i n g th e di s tr i ct cou r t ’ s i n ter pr etati on of th e

ter m s “ i n pati en t tr eatm en t s tay ” an d i ts f

i n d i n g th at L i l l i an was adm i tted “ f o r

s ev er e sy m ptom s

. ” P r em er a al s o ch al l en g es th e di s tr i ct cou r t’ s f i n di n g th at L i l l i an

“ r equ i r e[ d] a s tr

u ctu r ed setti n g wi th con

ti n u ed ar ou n d- th e- cl ock beh av i o r al car e”

f r om M ay 1
, 2014, to J u

n e 21, 2015. B as ed on th e ev i den ce, we con cl u de th at

th es e f i n di n g s wer e cl ear l y er

r o n eou s

.

F or ex am p l e, i n f i n di n g L i l l i an ’ s tr eatm en

t m edi cal l y n eces s ar

y , th e di s tr i ct

cou r t r el i ed on Dr

. L au

r a B r ockban

k’ s F ebr u ar y 2 014 p s y ch ol og i cal ev al u ati on , i n

3wh i ch Dr

. B r ockban k “ s t r o n g l y r ecom

m en ded” th at L i l l i an “ com

pl ete th e

pr og r am ” at E l ev ati on s

. H owev er , th er e i s n o ev i den ce to s u g g es t th at th i s

r ecom m en dati o n was al i g n ed wi th an y m edi cal n eces s i ty s tan dar d. T h e b as i s g i v en

f or Dr

. B r ockban

k’ s r ecom m en dati o n s i g n i f

i can tl y d epar ts f r om t h e Medi cal

P ol i cy , wh i ch s tates th at a pati en t m ay be d i s ch ar g ed f

r om r es i d en

ti al car e to a

l ower l ev el i f

, am on g oth er th i n g s , th e pati en

t “ h as n ot r ecen tl y m ade a su i ci de

attem pt or act of ser i ou s h ar

m to s el f ” an d h as l acked a “ cu

r r en t pl an f or s u i ci de or

s er i ou s h ar

m to s el f f

or at l eas t 24 h ou

r s

. ”

T h e di s tr i ct cou

r t f ou n d s u ppor t f or Dr

. B r ockban

k’ s r ecom m en dati on

becau se of L i l l i an ’ s pr i or “ h i s tor y of r u n n i n g away an d s u i ci dal i deati on ” an d

becau se i n

J u n e 2014, L i l l i an r epor

ted an u r g e to s el f

- h ar m an d E l ev ati on s s taf

f

br i ef l y ( f or on e day ) pl aced h er on s el f

- h ar m pr ecau ti on s

. Vi ewed i n l i g h

t of th e

f u l l r ecor d

, h owev er , th at ev i d en ce di d n ot m eet P l ai n ti f f s ’ bu r den to s h ow

L i l l i an ’ s m edi cal n eed f

or ar ou n d- t h e- cl ock m

on i t or i n g an d con f

i n em en t f r om M ay

2014 to J u

n e 2015.

Un der th e pr i n ci pl e of p ar ty pr es en t ati on , cou

r ts m u st pr es u m e “ t h at par ti es

r epr es en ted by com peten t cou n s el kn ow wh at i s b es t f

or th em , an d ar e r es pon s i bl e

f or adv an ci n g th e f

acts an d ar g

u m en t en ti tl i n g th em t o r el i ef

. ” Sineneng- Smith

,

140 S

. Ct. at 1579 ( al ter ati on om i tted) ( qu o ti n g Cas tr o v. U nited States
, 540 U. S

.

4375, 386 ( 2003) ( S cal i a, J

. , con cu r r i n g i n p ar

t an d con cu

r r i n g i n th e j u d g m en

t) )

.

T h at pr es u

m pti on n atu r al l y appl i es al l th e m

or e i n a cas e s u ch as t

h i s , i n v ol v i n g a

s peci al i zed ar ea of ci v i l l aw an d com peten t , h i g h l y ex

per i en ced cou

n s el on both

s i des

. See id. Ou

t o f a con cer n f or f ai r n es s , we do n ot r ev er s e th e deci si on bel ow

bu t i n s tead v acate an d r em an d f or r es ol u ti on of th e p ar

ty

- pr es en ted con tr ov er s y

.

See id. at 1581- 82.

E ach par ty t o bear i ts own cos ts

.

VACATED an d REM ANDED.

5