Opinion ID: 3064958
Heading Depth: 3
Heading Rank: 2

Heading: Alexandra’s Treatment

Text: In the fall of 2005, Alexandra’s mother (“Ms. Dupree”) approached Holman to get help for her daughter. Alexandra was 15 years old. One year earlier she had been diagnosed with diabetes and prescribed insulin, but failed to follow through with the treatment. She had already blacked out from drinking on multiple occasions and been using illegal drugs for two years. 2 The district court mistakenly focused instead on Section D (“NonContracted Providers-Inpatient Hospital”). The applicable section, and the one argued in Dupree’s trial brief, was Section C. 9934 DUPREE v. HOLMAN PROFESSIONAL COUNSELING Between August 26, 2005, and September 6, 2005, Ms. Dupree spoke with Holman representatives about finding an RTC for Alexandra. After being apprised of Alexandra’s substance abuse and diabetes, Holman provided Ms. Dupree with contact information for two contracted RTCs. Ms. Dupree said she would let Holman know if she was interested in them. To Alexandra’s therapist and UCLA doctors, Ms. Dupree instead indicated her preference for a third option: Visions Adolescent Treatment Program (“Visions”), an RTC in Malibu providing on-site diabetes treatment. The UCLA doctors wrote to Holman, recommending Alexandra be sent to Visions, even though it was “not currently covered by [Dupree’s] plan,” because, “according to [Ms.] Dupree,” it was the only facility that could manage Alexandra’s substance abuse and diabetic needs. In response to this letter and to Ms. Dupree’s statement that she was interested in Visions rather than the two contracted RTCs,3 Holman cautioned that “Visions is not in-network” and that Dupree’s insurance did not “carry an Out-of-Plan benefit.” Alexandra was admitted to Visions on September 7, 2005, for alcohol poisoning following a blackout. She stayed there until October 29, 2005. C. Administrative and District Court Proceedings In November 2005, Dupree submitted a claim to Holman requesting reimbursement for Alexandra’s treatment at Visions. Holman denied the claim as an uncovered out-ofplan benefit. Dupree appealed, and Holman reiterated its denial. Ms. Dupree tried two more times, and Holman conducted two medical review summaries in response, determining that (1) Alexandra was admitted to the out-of-network provider without authorization when contracted facilities were 3 After coverage for Visions was denied on administrative appeal, Ms. Dupree said she had determined that neither of the recommended facilities provided on-site diabetes treatment. DUPREE v. HOLMAN PROFESSIONAL COUNSELING 9935 recommended and appropriate, and (2) Alexandra’s condition did not constitute an emergency. Dupree then filed a complaint in district court. After a bench trial, that court found for Holman, determining that the insurer properly denied benefits for Alexandra’s use of the non-contracted provider. This timely appeal followed.