Source: https://www.lifeanddisabilitylaw.com/your-erisa-watch-fifth-circuit-holds-that-anthem-did-not-abuse-its-discretion-in-denying-coverage-for-bariatric-surgery/
Timestamp: 2019-04-18 10:53:13+00:00

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This week’s notable decision is Rittinger v. Healthy All. Life Ins. Co., No. 17-20646, __F.3d__, 2019 WL 391771 (5th Cir. Jan. 31, 2019), a case involving the denial of coverage for bariatric surgery and follow-up surgery for complications. The Fifth Circuit reversed the district court’s determination in favor of Rittinger and found that Anthem did not abuse its discretion in the handling of Rittinger’s appeals. This is yet another case where the standard of review makes all the difference. As the court explained, “[A]lthough not the paragon of procedural propriety, Anthem satisfied the very low, very deferential abuse-of-discretion standard.” Because the court found that Rittinger is not entitled to any damages, the court dismissed her cross-appeal to determine the exact dollar amount of damages she is owed.
[The plan does not cover] bariatric surgery, regardless of the purpose it is proposed or performed. This includes but is not limited to Roux-en-Y (RNY), Laparoscopic gastric bypass surgery or other gastric bypass surgery. Complications directly related to bariatric surgery that result in an Inpatient stay or an extended Inpatient stay for the bariatric surgery, as determined by Us, are not covered.
An exception to this exclusion is for conditions that include excessive nausea/vomiting. None of Rittinger’s preauthorization information mentioned excessive nausea/vomiting.
Rittinger’s husband emailed Anthem stating he would like to file an appeal for her hospitalizations. Anthem treated the email as a first-level appeal, gathered more information from her surgeons, obtained an independent peer review, and again denied coverage. Rittinger then hired an attorney who filed a second-level appeal including records which showed that Rittinger suffered from GERD and esophagitis, which is linked to nausea and vomiting, and she underwent surgery to address these problems. Anthem convened a five-person “Grievance Advisory Panel” to address the second-level appeal and the Panel concluded that the surgery was excluded from coverage.
Rittinger filed suit. On abuse of discretion review, the district court found that Anthem did not abuse its discretion when it treated Mr. Rittinger’s email as a first-level appeal but that it did abuse its discretion in denying the second-level appeal. The district court believed that Anthem’s construction of the plan’s terms directly contradicted their plain meaning and the evidence linking Rittinger’s GERD/esophagitis to nausea and vomiting was entitled to more weight.
The Fifth Circuit affirmed the district court’s determination that Anthem did not abuse its discretion when it treated Mr. Rittinger’s email as a first-level appeal. Though the plan’s grievance procedures do not supply an email address where appeals can be directed, the statement of “I would like to file an appeal” was naturally and reasonably read as a request to appeal.
Perhaps Paragraph 33 is best interpreted like Thanksgiving and holidays—as creating a Venn diagram of categories where GERD/esophagitis and excessive nausea/vomiting have some overlap. But we are not asking what is the best construction of Paragraph 33. We are asking whether Anthem’s construction was so egregiously wrong that it flouts the plan’s plain language and constitutes an abuse of discretion.
The court found the medical records contain a dearth of mention of nausea or vomiting. Though affidavits from friends and a doctor’s letter supported that Rittinger suffered from nausea and vomiting, the court found that Anthem cleared “the low, more-than-a-scintilla threshold.” Anthem did not have to credit Rittinger’s post-surgery letters over her pre-authorization documentation and Anthem’s consulting physician’s opinion.
This is what troubles me the most about this decision. The whole point of the appeals process is to be able to perfect the claim and provide information that the administrator deemed lacking in its initial review. Anthem characterized Rittinger’s appeal evidence as “self-serving” (like its denial of claims?) but there’s no doubt that her conditions of GERD/esophagitis causes nausea and vomiting. If one is to be bound by the inadequacy of her medical records, how can an appeal ever be won if a court will permit an insurance company to pay such short shrift to legitimate appeal evidence?
Jammal v. Am. Family Ins. Co., No. 17-4125, __F.3d__, 2019 WL 348716 (6th Cir. Jan. 29, 2019) (Before: BOGGS, CLAY, and ROGERS, Circuit Judges). On interlocutory appeal under 28 U.S.C. § 1292(b), the court reversed the district court’s determination that the insurance agents are employees for purposes of qualifying for ERISA benefits. The court held that the district court incorrectly applied “the Darden factors relating to (1) the skill required of an agent and (2) the hiring and paying of assistants.” The Agent Agreement, which states unambiguously that the agents are independent contractors, also swings the balance in favor of independent-contractor status. Judge Clay filed a dissenting opinion.
Vetter v. American Airlines, Inc. Pilot Long-Term Disability Plan, No. PWG-16-2833, 2019 WL 398679 (D. Md. Jan. 31, 2019) (Judge Paul W. Grimm). The court previously determined that the Plan’s decision not to award benefits before May 3, 2012, or after July 23, 2012, was not supported by substantial evidence and therefore an abuse of discretion. The court granted Defendant’s motion for reconsideration in part, and found that Plaintiff was not entitled to benefits before May 3, 2012, which is the date that the elimination period ended. The court denied reconsideration of its decision finding that Plaintiff was entitled to benefits after July 23, 2012.
Goss v. Aetna, Inc., No. 1:18-CV-02298-SCJ, __F.Supp.3d__, 2019 WL 386405 (N.D. Ga. Jan. 31, 2019) (Judge Steve C. Jones). The court denied Plaintiff’s motion to remand the case to Gwinnett County Superior Court. The court rejected all of Plaintiff’s arguments, including: (1) the Optum Defendants failed to comply with Georgia Superior Court Rule 4.2 prior to removal; (2) the Optum Defendants failed to properly and timely consent to removal; and (3) there was no federal question in Plaintiff’s operative complaint at the time of the removal sufficient to invoke ERISA preemption. Though Plaintiff ultimately withdrew the ERISA claim in the first amended complaint, the state law claims still rest on the same or similar allegations based entirely on her ERISA plan. Specifically, that her insurance benefits were being fraudulently paid to Optum.
Rittinger v. Healthy All. Life Ins. Co., No. 17-20646, __F.3d__, 2019 WL 391771 (5th Cir. Jan. 31, 2019) (Before HIGGINBOTHAM, GRAVES, and WILLETT, Circuit Judges). See Notable Decision summary above.
Todd R., et al. v. Premera Blue Cross Blue Shield of Alaska, No. C17-1041JLR, 2019 WL 366225 (W.D. Wash. Jan. 30, 2019) (Judge James L. Robart). The court concluded that Lillian R.’s residential treatment was medically necessary and covered under the Plan. Her initial admission to Elevations qualifies as an “inpatient treatment stay” under the sixth risk listed in Premera’s Medical Policy. “[A]lthough Lillian R. ultimately reached points in her treatment when she was ready to try out her new skills in a less structured and real life environment, which included short stints at home, these experiences were not inconsistent with her need to return to Elevations’ structured setting and continued around-the-clock behavioral care until she was medically ready for a complete discharge from the program.” (internal quotations omitted).
Bellevue v. 1199SEIU Health Care Employees Pension Fund, No. 17 CIV. 7430 (KPF), 2019 WL 400638 (S.D.N.Y. Jan. 31, 2019) (Judge Katherine Polk Failla). Plaintiff alleged violations of Sections 502(a)(1)(B), 503(a)(2), and 502(a)(3) of ERISA for Defendants’ failure to include certain overtime compensation he received between 2004 and 2013 in his pension benefit calculations. The court granted Defendants’ motion for summary judgment. The court determined that the hospital defendants are not ERISA fiduciaries and had no duty to notify Plaintiff of the Plan’s overtime exclusion, and they did not breach their obligations to provide the Fund with requested information. The court also determined that the Fund defendants did not breach their fiduciary duties by failing to safeguard and account for employer contributions and they did not violate ERISA disclosure obligations.
County of Monterey DBA Natividad Medical Center v. Blue Cross of California DBA Anthem Blue Cross, et al., No. 17-CV-04260-LHK, 2019 WL 343419 (N.D. Cal. Jan. 28, 2019) (Judge Lucy H. Koh). In this dispute over Anthem’s processing of Plaintiff’s trauma claims, the court granted Anthem’s motion to dismiss without prejudice. The court found that the Complaint fails to plead factual allegations with specificity, “including the specific claims, dates, explanations of benefits, and the ERISA plan provisions at issue.” The Complaint also insufficiently alleges standing. Plaintiff should allege the specific language of the assignment itself because whether an assignee has the standing to sue under ERISA depends on whether the claims at issue fall within the scope of the assignment.
Griffin v. Gen. Elec. Co., No. 18-10046, __F.App’x__, 2019 WL 350739 (11th Cir. Jan. 28, 2019) (Before JORDAN, BRANCH, GRANT, Circuit Judges). The court affirmed the district court’s dismissal of the pro se doctor’s complaint alleging gender and racial discrimination under Section 1557 of the Affordable Care Act, 42 U.S.C. § 18116. GE brought the same or similar challenges to other non-minority providers who brought claims against it.
Brenton v. F.M. Kirby Center for The Performing Arts, No. CV 17-89, 2019 WL 367051 (M.D. Pa. Jan. 30, 2019) (Judge Malachy E. Mannion). In order to cut money from the budget, Defendant consolidated Plaintiff’s position with her assistant’s position and did not select Plaintiff for the newly created position. The court found that there was no direct or circumstantial evidence that Plaintiff was targeted for termination due to her benefits eligibility under the company’s 403(B)-plan in violation of Section 510 of ERISA. The court explained that establishing a prima facie case under Section 510 is not the same as establishing the elements of a Title VII retaliation claim.
P&G Health & Longterm Disability Plan v. Molinary, No. 1:18-CV-283, 2019 WL 358936 (S.D. Ohio Jan. 29, 2019) (Judge Timothy S. Black). Plaintiff alleged that Defendant began working for another employer while he was still receiving short-term disability benefits under the Plaintiff’s disability plan. Defendant repaid only $1,000 of the overpayment, leaving a balance due of $7,520.94. The court granted Plaintiff default judgment in its favor on its claims of breach of contract, unjust enrichment, breach of fiduciary duty/ERISA trust, and constructive trust. In addition to the unpaid benefits, the court awarded Plaintiff $481.88 in costs, plus post judgment interest at the statutory rate.
Boards of Trustees of The Texas Carpenters and Millwrights Health and Welfare Fund v. Refined General Contractors, LLC, No. 5:18-CV-00465-XR, 2019 WL 369144 (W.D. Tex. Jan. 30, 2019) (Judge Xavier Rodriguez). The court granted Plaintiffs’ motion for default judgment and awarded “Plaintiffs the sum of $71,262.40, including the delinquency sum, interest, and liquidated damages, but excluding attorney fees and costs.” Plaintiffs can file an application for fees within 14 days of judgment.
New Orleans Employers International Longshoremen’s Assoc. v. Maritime Security, Inc., No. CV 17-7430, 2019 WL 342440 (E.D. La. Jan. 28, 2019) (Judge Jay C. Zainey). The court granted Plaintiff’s motion as to the issue of withdrawal liability.
Trustees of Suburban Teamsters of N. Illinois Pension Fund v. E Co., No. 18-2273, __F.3d__, 2019 WL 348770 (7th Cir. Jan. 29, 2019) (Before Easterbrook, Barrett, and Scudder, Circuit Judges). The court held that fund’s notice of withdrawal liability did not violate defendants’ due process rights.
Patt v. H & S Contracting, Inc., No. CV 18-2592 (DWF/LIB), 2019 WL 413558 (D. Minn. Feb. 1, 2019) (Judge Donovan W. Frank). The court granted Plaintiffs’ Motion for Entry of Judgment in the amount of $21,061.22 against Defendant H & S Contracting, Inc.
Nesse v. Lakewest Excavating LLC, No. CV 18-703 (PAM/SER), 2019 WL 337608 (D. Minn. Jan. 28, 2019) (Judge Paul A. Magnuson). Lakewest is liable to the Funds in the amount of $16,450.05 for unpaid contributions and liquidated damages for the period of January 2018 through September 2018, and is liable to the Funds in the amount of $6,578.72 for the Funds’ reasonable attorneys’ fees and costs incurred in pursuing the delinquent contributions.
Bricklayers and Trowel Trades International Pension Fund (IPF) v. The Denver Marble Company, No. 16-CV-02065-RM, 2019 WL 399228 (D. Colo. Jan. 31, 2019) (Judge Raymond P. Moore). The Court denied without prejudice Plaintiffs’ Renewed Motion for Entry of Default Judgment and for an Award of Attorneys’ Fees and Non-Taxable Costs.

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