Opinion ID: 3064958
Heading Depth: 3
Heading Rank: 1

Heading: The Behavioral Health Insurance Plan

Text: Dupree’s employer, Beverly Hills Hotel, contracted with Holman for behavioral health insurance coverage. Holman agreed to provide behavioral health services “through Providers pursuant to the Schedule of Benefits,” allowing that, if enrollees chose to instead use non-contracted providers, they would do so at their own expense, “except as otherwise provided in this Group Plan Contract.”1 This language is echoed in other contract provisions: declining to provide reimbursement “except in emergency cases or as outlined in this Group Plan Contract,” and declining to cover non-emergency treatment by non-contracted providers “unless otherwise stated in the Agreement.” It also appears in the “Exclusions” section, which denies coverage for services performed by noncontracted providers except in emergency cases or as “otherwise authorized by the Plan.” However, the plan also excludes coverage for “[a]ny service that is not specifically listed as a covered benefit.” 1 We quote from the February 2004 version of the group contract. The parties agreed that the December 2004 version was the applicable one, but have identified no differences between the two versions of the group contract. The December 2004 version of the “Evidence of Coverage & Disclosure” provided by the hotel to its employees is also consistent with the February 2004 policy language. There are differences between the February 2004 and December 2004 benefit schedules. Nonetheless, Dupree’s counsel said during oral argument that those differences were not significant to her theory of the case, and so we do not consider them. The portions of the benefit schedule we quote here are the same in both versions. DUPREE v. HOLMAN PROFESSIONAL COUNSELING 9933 The plan defines providers as licensed, experienced persons working individually or within a clinic who are “employed or under contract with Holman to deliver Behavioral Health Services to Enrollees.” The definition section then distinguishes between contracted providers (those who have “contracted with Holman to deliver specified services”) and noncontracted providers (those without such a contract), while cautioning that “Enrollees may be liable for the cost of nonemergency services provided by Non-Contracted Providers.” Most relevant to this appeal, the Holman plan includes care at a “Sub-Acute Care Facility,” which is any RTC that “has entered into a provider agreement with Holman.” In the benefit schedule, Category III, Section C (entitled “Residential Treatment, Transitional Care, Day Treatment, Partial Hospitalization”) constitutes the RTC benefit provided for drug and alcohol treatment.2 Category III also includes other sections detailing additional drug and alcohol treatment benefits: (A) “Outpatient,” (B) “Contracted Providers-Inpatient Hospital,” (D) “Non-Contracted Providers-Inpatient Hospital,” and (E) “Non-Contracted Providers-Outpatient Services.” Section D only covers non-contracted care in an emergency situation. Section E is not limited to emergencies, but has written below its description: “NOT A COVERED BENEFIT.”