Opinion ID: 777312
Heading Depth: 3
Heading Rank: 2

Heading: Specific Exclusions

Text: 28 Under the Final Section of the Plan's Schedule of Benefits and Exclusions, the Plan lays out thirty-five specific exclusions from coverage. The Plan provides in relevant part: 29 Except as specifically covered in any Attachment hereto, the following services and benefits are excluded from coverage hereunder.... 30 13. Private or special duty nursing, unless determined to be Medically Necessary and approved in advance by Health Plan. 31 The Fays' claim for full-time, in-home nursing care falls squarely within this exclusion. The Fays read the language of the exclusion to require that Oxford provide private or special duty nursing generally, barring from coverage only that care not found Medically Necessary. They argue that the exclusion would be unnecessary if such services were not generally available. This interpretation, while not wholly unreasonable, appears to overstate the power of the exclusion's unless determined to be Medically Necessary clause. 32 The Home Care provision establishes that limited, short-term, in-home care is generally available under the Plan. Notably, even short-term home care is available only on a finding of medical necessity. 7 The private duty exclusion emphasizes the short-term nature of the generally available in-home care by specifically excluding full-time, in-home care from Oxford's regular benefits. As the Fays allege, however, the language of the exclusion suggests that in certain cases meeting the tests of Medical Necessity and prior approval by the Plan, Oxford may choose to make an exception to its general exclusion. 33 While the Plan promises general Medical Care in the form of office visits and consultations, Hospital and Skilled Nursing Facility visits, and periodic physical examinations, this broad guarantee of basic services is constrained by the rest of the Plan's provisions. The Plan does not regularly provide the type of service the Fays seek — full-time, in-home care — but instead specifically excludes such care from its purview. Although the exclusion potentially suggests the limited availability of the private duty service, that service is confined to special cases on the basis of medical necessity and prior approval. The district court thus correctly found that the Plan does not generally allow the type of care Mr. Fay requests. 34 Like the district court, this Court is reluctant to draw a duty from an exclusion. Even if the placement of the private duty provision in the exclusion section suggests, as the district court believes it does, Oxford's intent to provide no private duty care, the language of the private duty exclusion, viewed objectively, is ambiguous. See O'Neil, 37 F.3d at 59 (requiring an objective review of plan provisions). Construing this ambiguity in favor of the beneficiary, this Court finds itself required to decide if Mr. Fay could have qualified for full-time home care under the apparent exception to the private duty bar. See Masella, 936 F.2d at 107. To so decide, this Court must determine whether Oxford's conclusion that such care was not medically necessary for Mr. Fay prevents the Fays from receiving private duty care as an exceptional case.