Opinion ID: 6317310
Heading Depth: 3
Heading Rank: 2

Heading: Additional Claims for Coverage

Text: As the First DOS claims were being reviewed and appealed, J.W. continued to be treated at CALO, and CALO continued to submit claims for those residential services to United. However, United denied these claims, again finding a lack of medical necessity for inpatient treatment. As the claims were denied, United sent multiple Explanation of Benefits (“EOB”) letters to Wilson, setting out the reasons for United’s decision and explaining Wilson’s rights and responsibilities under ERISA and the Plan. On January 26, 2017, Wilson’s counsel faxed a letter to United indicating that she had been “retained to represent [Wilson] in connection with the appeal of [United’s] denial 6 of his health insurance benefits.” J.A. 2930. The letter’s subject line identified three specific claim numbers, which were for CALO’s services provided during the time periods the parties and district court later designated as the Second DOS. The letter also stated that Wilson’s “appeal is for the claims referenced above as well as any and all denied claims related to treatment received at [CALO].” Id. The January 26 letter identified two purposes for writing. First, it stated that Wilson “do[es] wish a review of the denial of Mr. Wilson’s claim pursuant to 29 U.S.C. § 1133” and indicated that although counsel “request[ed] that [United] begin [its] review,” she did “not wish for [United] to complete the review until [she was] able to submit to [United] all of Mr. Wilson’s medical records,” which she was in the process of obtaining. Id. Counsel indicated that it was “absolutely essential” that United consider those records “as a part of this review.” Id. Second, the letter asked United for “a complete copy of each and every document upon which [it had] based [its] denial of Mr. Wilson’s claim,” including “any medical documents, substantive documents, the plan document and any internal guidelines or regulations which [United] ha[d] used in evaluating [the] claim.” J.A. 2931. As support for the right to obtain copies of these records, the letter referenced “29 U.S.C. § 1132(c) and 29 U.S.C. § 1133 as interpreted by the Fourth Circuit Court of Appeals in Ellis v. Metropolitan Life Insurance Company, 126 F.3d 228 (4th Cir. 1997) and the Code of Federal Regulations interpreting 29 U.S.C. § 1133.” Id. The letter reiterated its position that Wilson must “be given the documentation upon which his claim has been denied so 7 that [he has] a full and fair opportunity to respond to the same should he deem it appropriate.” Id. Attached to the January 26 letter were two signed documents: (1) a “Confirmation of Representation and Authorization for Release of Records and Reports,” Wilson’s Letter re: Court Order at 1, Wilson v. UnitedHealthcare Ins. Co., No. 20-2044 (4th Cir. filed Dec. 13, 2021), ECF No. 45, and (2) a “Medical Authorization for Release of Records and Other . . . Identifying Information” to comply with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) (“the HIPAA authorization form”), J.A. 2932. The confirmation of representation form contains a signature on a line for the “client” to sign, followed by Wilson’s social security number and birthdate. It states that the attorney who sent the January 26 letter had been retained to represent Wilson “in connection with [his] claim for health insurance benefits” and that Wilson authorized United to send his counsel “any and all information, which may be requested, from any medical provider, [his] insurance company or [his] employer regarding [him].” Wilson’s Letter re: Court Order at 4, ECF No. 45. The HIPAA authorization form similarly sought to authorize counsel to obtain copies of “patient” J.W.’s records that would otherwise be protected by privacy laws. In a section setting out the “Authorization and Scope” of the release, it identified ten categories of materials, including medical and psychiatric records, hospital records, laboratory reports, and medical opinions. J.A. 2932. It also authorized various entities to “discuss [J.W.’s] history, condition, treatment, claim and bills” with counsel. Id. The HIPAA authorization form acknowledged that “to be valid[, the form] must comply with 45 C.F.R. 8 § 164.508.” Id. The form contains an illegible signature on the line for a patient to “sign[] on his or her own behalf.” Id. The lines for a client to sign “on behalf of another person” and to indicate the basis for that authority to sign are blank. Id. Although United internally categorized the January 26 letter as an attorney’s request for release of information, it did not respond to the letter, produce any documents, or initiate an appeal. On February 24, 2017, counsel sent a second letter to United, which again specifically identified the three claim numbers associated with the Second DOS. It referenced the January 26 letter as having “notified” United that Wilson “was appealing” the denial of J.W.’s benefits and attached a copy of the prior letter. J.A. 2933. The letter observed that counsel had “not received any documents from [United] which [were] responsive to [her] attached request for documents.” Id. And it reiterated that counsel could not “prepare or submit any substantive documents . . . to be considered on review until [United] provide[d her] the” previously requested documents. Id. A response from United was requested within ten days. Further, the letter stated that if United did not provide the requested documents within the ten days, Wilson would be left with the assumption “that further attempts to exhaust administrative remedies [were] futile” and would instead “file suit” under ERISA. Id. United again internally categorized the letter as an attorney’s request for release of information, but did not respond, provide copies of documents, or initiate an appeal. 9