Opinion ID: 35610
Heading Depth: 2
Heading Rank: 3

Heading: dismissal of mayeaux's benefits claim

Text: 18 Mayeaux asserts two reasons why the trial court erred in granting summary judgment dismissing her benefits claim. First, Mayeaux insists that the letter from BCBS's general counsel inviting a second opinion was a contractual offer which, when she accepted it by tendering Dr. Deming's report, created a binding obligation on BCBS's part to provide benefits. Second, Mayeaux challenges BCBS's interpretation of the Adler Plan as precluding coverage for Dr. Hyman's prescribed treatment as investigative.
19 Following BCBS's denial of Mayeaux's pre-authorization request, counsel for the parties exchanged a series of letters discussing the basis for BCBS's decision. In one of these letters to Mayeaux's lawyer, BCBS's general counsel stated: 20 Blue Cross and Blue Shield of Louisiana, as an insurer, is not obligated to pay for medical treatment which, in our sole discretion, is not medically appropriate. Further, we are not obligated to pay for the trial and error practice of medicine. It may be true that Dr. Hyman's treatment is good medicine; however, the manufacturer of the medication states otherwise and the terms of our subscriber contract allow us to deny benefits for this reason. Finally, I would like to make it clear that we are not closed-minded regarding this issue. We have urged our subscriber to seek the advice of another physician and, if that physician agrees that Dr. Hyman's treatment is appropriate, then we will continue to pay claims. 19 21 Ignoring everything but the final sentence quoted, Mayeaux argues that this statement was a legal offer, which she accepted by submitting the concurring medical opinion of Dr. Deming. She contends that the effect of the letter was that the health insurer [BCBS] gave up its discretionary authority to determine whether the benefits were appropriate (medically necessary). 22 In granting summary judgment in BCBS's favor, the district court observed that even if that claim was not preempted by ERISA, counsel's letter attempting amicable settlement of an issue that was clearly headed towards litigation did not create any contractual relationship between the principles [ sic ] unless those principles [ sic ] expressly gave the attorney authority to do so. Relying on Article 2997 of the Louisiana Civil Code, which requires a principal to give authority expressly before a mandatary (agent) can enter into a compromise, 20 the district court concluded that the letter from BCBS's general counsel could create no binding contractual agreement between Mayeaux and BCBS, irrespective of Mayeaux's proffer of Dr. Deming's opinion. 23 The district court correctly granted summary judgment against Mayeaux on her claim for breach of contract. When BCBS's general counsel sent the subject letter to Mayeaux's attorney, this dispute was plainly heading toward litigation. BCBS had consistently maintained that its denial was based on the express exclusion of investigational treatment from coverage under the Adler Plan. Mayeaux's attempt to create a state contractual obligation by isolating a single sentence out of a single letter from BCBS's lawyer to hers — a letter that was part of an extensive ongoing dialogue between the parties' attorneys — is feckless. Indeed the four corners of what Mayeaux would have us deem to be a binding agreement between the parties would necessarily encompass the whole chain of correspondence between their respective counsel; and Article 2050 of the Louisiana Civil Code requires that [e]ach provision in a contract must be interpreted in light of the other provisions so that each is given the meaning suggested by the contract as a whole. 21 24 In light of the whole exchange, BCBS's lawyer's statement was nothing more than an invitation for Mayeaux to demonstrate that the HDAT was not investigational — that it was, contrary to BCBS's position, standard medical treatment generally accepted by the wider medical community. On summary judgment, Mayeaux adduced no evidence to illustrate an intention by BCBS to relinquish its discretionary authority to determine what constitutes standard medical treatment under the Adler Plan. Mayeaux's attempt to characterize BCBS's letter as an offer inviting her acceptance misses the mark. 22
25 Mayeaux also contends that the Adler Plan's administrator improperly denied coverage for Dr. Hyman's prescribed therapy and that the district court erroneously affirmed that decision. We disagree. 26 As a preliminary matter, Mayeaux advances that the district court failed to apply the correct standard of review. Mayeaux maintains that the Adler Plan administrator's decision is tainted by a conflict of interest, requiring the district court to employ our Vega case's sliding scale standard of review to evaluate whether there was an abuse of discretion. 23 Mayeaux's assertion in this regard is baseless: The record makes clear that the district court expressly applied Vega and accorded the administrator's decision less than full deference. 27 The essence of Mayeaux's substantive challenge to the Adler Plan administrator's decision is that the plan's wording does not contain an express exclusion for the investigational use of drugs. Mayeaux's argument is a red herring. As we explained earlier, 24 the Adler Plan specifically excludes benefits for investigational treatments and any procedures that BCBS determines not to be standard medical treatment for that particular condition. 28 Simply put, Mayeaux has failed to identify sufficient record evidence on appeal to support the Plaintiffs' contention that HDAT, as prescribed by Dr. Hyman for the connective tissue malady that he diagnosed in Mayeaux, is standard medical treatment. Mayeaux, of course, relies on Dr. Deming's medical opinion to make this showing. Even assuming arguendo that Dr. Deming's opinion provided some additional support for the Plaintiffs' position that HDAT is not purely investigational, we certainly cannot conclude that the Adler Plan administrator's decision was an abuse of discretion. The administrator could readily have concluded, as he did, that one concurring medical opinion is inadequate to establish that HDAT is a standard medical treatment. As such, Mayeaux has failed to show abuse of discretion by the administrator of the Adler Plan, so the district court's grant of summary judgment on Mayeaux's denial-of-benefits claim was proper.