Court Opinion

ID: 3178033
Source: CourtListenerOpinion
Date Created: 2016-02-17 22:03:54.267895+00
Date Added: 2024-06-11T09:17:48.328825
License: Public Domain

United States Court of Appeals
                     For the First Circuit

No. 15-1531

       STEPHANIE C., Individually and as Guardian of M.G.,

                      Plaintiff, Appellant,

                               v.

     BLUE CROSS BLUE SHIELD OF MASSACHUSETTS HMO BLUE, INC.,

                      Defendant, Appellee.

          APPEAL FROM THE UNITED STATES DISTRICT COURT
                FOR THE DISTRICT OF MASSACHUSETTS

          [Hon. Denise J. Casper, U.S. District Judge]

                             Before

                    Lynch, Selya and Kayatta,
                         Circuit Judges.

     Brian S. King, with whom Law Firm of Brian S. King and
Jonathan M. Feigenbaum were on brief, for appellant.
     Joseph D. Halpern, with whom Law Office of Joseph Halpern and
Donald J. Savery were on brief, for appellee.

                        February 17, 2016
          SELYA, Circuit Judge.     In this benefits-denial case,

brought pursuant to the Employee Retirement Income Security Act of

1974 (ERISA), codified in relevant part at 29 U.S.C. §§ 1001-1461,

Stephanie C. (Stephanie), individually and on behalf of her minor

son M.G., challenges a decision of the claims administrator, Blue

Cross Blue Shield of Massachusetts HMO Blue, Inc. (BCBS), partially

denying her claim for benefits. The denial related to some charges

incurred during M.G.'s stay at a residential/educational mental

healthcare facility. The district court upheld the partial denial.

See Stephanie C. v. BCBS, No. 13-13250, 2015 WL 1443012, at *12

(D. Mass. Mar. 29, 2015).

          In this venue, Stephanie asserts that the district court

erred in failing to find that BCBS committed procedural violations;

that the court appraised her benefits-denial claim through the

wrong lens; and that the court, in all events, erroneously upheld

the partial denial of benefits.   We reject Stephanie's claims that

BCBS committed procedural violations.    From that point forward,

however, the case raises important questions concerning what a

plan sponsor or claims administrator must do to reserve discretion

in the handling of benefits claims.   Here, the district court did

not hold BCBS to these obligations and, thus, employed the wrong

standard of review when considering the partial denial of benefits.

Accordingly, we vacate the district court's judgment and remand

for further proceedings consistent with this opinion.

                              - 2 -
I.   BACKGROUND

             Stephanie's son, M.G., is a derivative beneficiary of an

ERISA-regulated group health insurance plan (the Plan) furnished

by his father's employer, Harmonix Music Systems, Inc. (Harmonix).

The Plan is denominated as a "Preferred Blue PPO Preferred Provider

Plan," the terms of which are set out in a subscriber certificate

(the Certificate).     In pertinent part, the Certificate makes clear

that coverage under the Plan remains subject to a determination of

medical necessity made by BCBS.        It specifies that the Plan covers

treatment for psychiatric illnesses, including biologically based

conditions (e.g., autism) and, for children until age nineteen,

for non-biologically based conditions (e.g., behavioral problems).

Such   benefits   do   not   accrue    for     residential,      custodial,   or

medically     unnecessary    services,    such      as   those   performed    in

"educational,     vocational,     or     recreational      settings."         The

Certificate also stipulates that only the least intensive type of

setting   required     for   treatment    of    a   condition    will   receive

approval.     Any non-emergency inpatient course of treatment needs

approval before the patient is admitted to the facility.

             The premium account agreement (the PAA) defines the

relationship between participating employers — such as Harmonix —

and BCBS. It provides that ERISA governs the claims administration

framework.     Under it, Harmonix is the plan administrator and BCBS

is the claims administrator.      The PAA further states that BCBS "is

                                   - 3 -
the fiduciary to whom [Harmonix] ha[s] granted full discretionary

authority" and that "[a]ll determinations of [BCBS] . . . will be

conclusive and binding on all persons unless it can be shown that

[a particular] determination was arbitrary and capricious."

           M.G.   experienced   a    number   of   mental   health   issues

beginning in early childhood. A detailed description of his mental

health history is set forth in the district court's rescript, see

Stephanie C., 2015 WL 1443012, at *1-6, and we assume the reader's

familiarity with that account.         For present purposes, a sketch

(concentrating on the pertinent period) suffices.

           M.G.'s condition intensified in severity in the summer

of 2010 (the summer between his freshman and sophomore years in

high school). At that time, he became physically aggressive toward

his parents and attended weekly mental health therapy sessions.

Although enrolled in an intensive outpatient educational facility,

he continued to exhibit aggressive behavior that led to multiple

arrests.   His problems escalated because he steadfastly refused to

take medications despite a court order requiring him to do so.

           Concerned about the apparent inadequacy of his care,

Stephanie enrolled M.G. (at her own expense and without prior

approval) in Vantage Point by Aspiro (Aspiro), a wilderness therapy

program based in Utah, which specializes in neurodevelopmental

                                    - 4 -
disorders.1 M.G. remained at Aspiro from October of 2010 to January

of 2011.        His psychological evaluators there diagnosed him as

having     Asperger's   Syndrome,      anxiety    disorder,       and   attention

deficit and hyperactivity disorder.              Noticing some improvement,

they recommended that he continue therapy in a longer-term setting.

             On the advice of a consultant and without prior approval,

Stephanie proceeded to enroll M.G. in Gateway Academy (Gateway),

a private school treatment center in Utah that BCBS insists is

"out of network" (that is, not in a contractual relationship with

BCBS). While at Gateway, M.G.'s aggressive and emotionally erratic

behavior     continued;      among     other     things,     he       engaged    in

inappropriate sexual contact and committed a variety of petty

criminal offenses.

             In April of 2011, Harmonix submitted claims to BCBS for

three sets of psychiatric evaluations and consultation services

(performed during the period from January 27, 2011 to February 23,

2011) in connection with M.G.'s admission to Gateway.                     In late

June,    BCBS    informed   Harmonix   that     Gateway    was    a   non-covered

provider but that it would cover the three sets of evaluations "as

a   one-time     exception."     Gateway       itself   submitted       claims   in

September of 2011 and March of 2012 seeking reimbursement for

     1The Aspiro charges are not at issue in this appeal.      The
partial denial of benefits challenged by Stephanie relates only to
M.G.'s subsequent enrollment at Gateway Academy (discussed infra).

                                     - 5 -
principally residential services rendered to M.G. dating back to

January of 2011.

             In an informal process, BCBS denied these room and board

claims because the services were not medically necessary and the

submitted documentation did not support the need for an inpatient

admission.     In an explanatory letter dated May 25, 2012, BCBS

advised M.G.'s father that its denial of benefits was based largely

upon an evaluation conducted by Dr. Elyce Kearns, a psychiatrist-

reviewer, who relied upon "InterQual," a nationally recognized set

of criteria used to assess the level of care for mental health

patients. Given Dr. Kearns' evaluation, BCBS concluded that M.G.'s

"clinical condition does not meet the medical necessity criteria

required for an acute residential psychiatric stay."

             About a year later, Stephanie requested and received a

sheaf of pertinent records from BCBS.         She then contested the

denial of coverage through BCBS's internal review process.          In

support of her appeal, Stephanie furnished documentation from

M.G.'s psychotherapists, evaluators, and educators in addition to

police reports and juvenile court records.         Collectively, these

materials described M.G.'s difficulties involving physical and

verbal aggression, emotional volatility, lack of impulse control,

and   thinking    errors.    This   pattern   of   conduct,   Stephanie

maintained, posed a danger to M.G. and to others.

                                 - 6 -
           A     second     psychiatrist-reviewer,     Dr.     Kerim     Munir,

scrutinized the administrative record and recommended that BCBS

uphold the denial of benefits. He cited the absence of any medical

necessity for the placement and reiterated the conclusions of the

first psychiatrist-reviewer.         On June 19, 2013, BCBS denied the

internal appeal in a letter to Stephanie.

           Stephanie repaired to the federal district court, suing

to recover the denied benefits.          See 29 U.S.C. § 1132(a)(1)(B).

In due course, the parties cross-moved for summary judgment.2               The

district court granted BCBS's motion and denied Stephanie's cross-

motion.   See Stephanie C., 2015 WL 1443012, at *12.             This timely

appeal followed.

II.   ANALYSIS

           We    subdivide    our   analysis   into   two    segments,    first

addressing Stephanie's claimed procedural irregularities and then

addressing the benefits-denial claim itself.

                   A.     Alleged Procedural Violations.

           At the outset, Stephanie argues that BCBS committed

serious procedural violations in failing to engage in dialogue

      2 As we have explained before, motions for summary judgment
in this context are nothing more than vehicles for teeing up ERISA
cases for decision on the administrative record. See Scibelli v.
Prudential Ins. Co., 666 F.3d 32, 40 (1st Cir. 2012). The burdens
and presumptions normally attendant to summary judgment practice
do not apply. See id.

                                    - 7 -
with her, to answer her questions, and to take into account the

materials that she submitted in the course of the internal review.

Affording de novo review to these claims of error, see Wenner v.

Sun Life Assur. Co., 482 F.3d 878, 881 (6th Cir. 2007), we reject

them.

              ERISA requires that every benefit plan

        (1) provide adequate notice in writing to any
        participant or beneficiary whose claim for benefits
        under the plan has been denied, setting forth the
        specific reasons for such denial, written in a manner
        calculated to be understood by the participant, and (2)
        afford a reasonable opportunity to any participant whose
        claim for benefits has been denied for a full and fair
        review by the appropriate named fiduciary of the
        decision denying the claim.

29   U.S.C.    §   1133.    The   Secretary   of    Labor   has    promulgated

interpretive       regulations,   which   mandate    that    the    denial    of

benefits      spell   out   the   specific    reasons       for    an   adverse

determination, delineate the particular plan provisions on which

the determination rests, furnish a description of any additional

material necessary to perfect the claim, and provide a description

of the plan's review procedures and applicable time limits.                  See

29   C.F.R.    §   2560.503-1(g)(1).      These    requirements     serve    the

salutary purpose of ensuring that a claimant is told the reasons

for a denial of her benefits claim and how to take an internal

appeal if such a denial should occur.              See Niebauer v. Crane &

Co., Inc., 783 F.3d 914, 926-27 (1st Cir. 2015); DiGregorio v.

                                    - 8 -
Hartford Comprehensive Emp. Benefit Serv. Co., 423 F.3d 6, 14 (1st

Cir. 2005).

             The "full and fair review" contemplated by section 1133

entails a process that permits a claimant to supply supplementary

"written     comments,        documents,    records,   and    other    [related]

information"      to    the     claims     administrator.      See    29   C.F.R.

§ 2560.503-1(h)(2). In turn, the claims administrator must furnish

the claimant, upon request and free of charge, all records and

documents relevant to the claim. See id. The claims administrator

also   has   a   duty   to     consider    the   materials   submitted     by   the

claimant.    See id.     Last but not least, even if the claimant shows

that procedural irregularities have occurred in the course of a

review, we typically require her to show prejudice as well.                     See

Bard v. Bos. Shipping Ass'n, 471 F.3d 229, 240-41 (1st Cir. 2006);

Recupero v. New Eng. Tel. & Tel. Co., 118 F.3d 820, 840 (1st Cir.

1997).

             In the case at hand, BCBS's May 25 letter apprised

Stephanie, clearly and concisely, of the reason why BCBS was

denying payment for some of Gateway's services: "your child's

clinical condition does not meet the medical necessity criteria

required for an acute residential psychiatric stay in the area of

symptoms/behaviors."          Even in the absence of a discussion directly

engaging with the Plan's medical necessity criteria, Stephanie

received a sufficiently definite explanation of the reason for the

                                         - 9 -
denial.   See, e.g., Cooper v. Hewlett-Packard Co., 592 F.3d 645,

652-54 (5th Cir. 2009); Orndorf v. Paul Revere Life Ins. Co., 404

F.3d 510, 526 (1st Cir. 2005); see also Juliano v. Health Maint.

Org. of N.J., Inc., 221 F.3d 279, 287 (2d Cir. 2000) ("The purpose

of [the 'full and fair review'] requirement is to provide claimants

with   enough    information    to     prepare    adequately     for   further

administrative    review   or   an    appeal     to   the    federal   courts."

(alteration in original) (quoting DuMond v. Centex Corp., 172 F.3d

618, 622 (8th Cir. 1999))).       Though the claims administrator must

give particular reasons for the denial of benefits, see 29 U.S.C.

§ 1133(1); 29 C.F.R. § 2560.503-1(g)(1)(i), it need not spell out

"the   interpretive   process     that   generated     the    reason   for   the

denial," Gallo v. Amoco Corp., 102 F.3d 918, 922 (7th Cir. 1996).

           BCBS's letter ended with an outline of the relevant

internal appeal procedures and, thus, substantially complied with

that aspect of the ERISA notice requirements.                See Niebauer, 783

F.3d at 927; Terry v. Bayer Corp., 145 F.3d 28, 39 (1st Cir. 1998).

The record makes manifest that Stephanie developed an effective

claim and was able to navigate BCBS's internal review process.

           Stephanie's     next       procedural      claim      is    likewise

unavailing.      When Stephanie pursued her internal appeal, she

requested that BCBS furnish her with M.G.'s claim-related medical

records. BCBS complied in a timely manner. Stephanie had an ample

opportunity, after receiving those records, to supply comments and

                                     - 10 -
supporting materials in conjunction with her internal appeal.                  She

perfected that appeal by means of a grievance letter attaching

well over 465 pages of supporting documents.

            By letter dated June 19, 2013, BCBS reiterated its

partial denial of benefits.           Although Stephanie contends that

BCBS's denial failed to take into account the supporting materials

that she had submitted (particularly those that came from M.G.'s

psychotherapists), that is sheer speculation.                 The mere act of

upholding a denial of benefits cannot mechanically be equated with

overlooking medical evidence that tends to support a different

outcome.    See Terry, 145 F.3d at 39.            Nor was BCBS obliged to

accept      unquestioningly      the         pronouncements        of        M.G.'s

psychotherapists:    "[n]othing       in     [ERISA]   suggests       that    plan

administrators must accord special deference to the opinions of

treating physicians."      Black & Decker Disab. Plan v. Nord, 538

U.S. 822, 831 (2003).

            Relatedly,    Stephanie        complains   that    BCBS     did     not

directly answer all of her questions.              But even though a plan

participant is entitled to have the claims administrator engage in

a meaningful dialogue and clearly communicate the reasons for its

actions, ERISA creates no obligation for claims administrators to

respond    exhaustively   to   each    and    every    list   of   questions      a

participant propounds.

                                  - 11 -
            In sum, Stephanie received the full and fair internal

review that 29 U.S.C. § 1133 prescribes.           Throughout, BCBS engaged

in a sufficiently meaningful dialogue with Stephanie about her

claim.      It assessed her original claim with the help of an

independent psychiatrist-reviewer and engaged a second independent

psychiatrist-reviewer to ensure adequate consideration of the

additional materials that Stephanie submitted on appeal.

            If more were needed — and we do not think that it is —

Stephanie    has    failed    to    show   prejudice   attributable   to    any

purported procedural irregularity. This failure, in and of itself,

is fatal to her procedural claims.           See Niebauer, 783 F.3d at 927.

            That ends this aspect of the matter.            For the reasons

elucidated above, we hold that Stephanie's procedural violation

claims lack force.

                               B.    The Merits.

            This brings us to the merits: Stephanie's claim that the

district    court   erred     in    upholding   BCBS's   partial   denial   of

benefits.    Stephanie's initial gambit is that the district court

employed the wrong standard of review.          We begin — and end — there.

            We must assay the Plan "in order to determine the

standard of judicial review applicable to a claims administrator's

denial of benefits."         McDonough v. Aetna Life Ins. Co., 783 F.3d

374, 379 (1st Cir. 2015).          The default rule favors de novo review:

a challenge to a denial of benefits is to be reviewed de novo

                                      - 12 -
"unless the benefit plan gives the administrator or fiduciary

discretionary authority to determine eligibility for benefits or

to construe the terms of the plan."          Firestone Tire & Rubber Co.

v. Bruch, 489 U.S. 101, 115 (1989).        Moreover, such authority must

be expressly provided for, see Rodriguez-Abreu v. Chase Manhattan

Bank, N.A., 986 F.2d 580, 584 (1st Cir. 1993), and notice of that

reservation must appropriately be given to Plan participants, see

Gross v. Sun Life Assur. Co., 734 F.3d 1, 14 (1st Cir. 2013)

("[T]he critical question is whether the plan gives the employee

adequate notice that the plan administrator is to make a judgment

within the confines of pre-set standards, or if it has the latitude

to shape the application, interpretation, and content of the rules

in each case." (quoting Diaz v. Prudential Ins. Co., 424 F.3d 635,

639-40 (7th Cir. 2005))).        Where the delegation of discretionary

authority   is    sufficiently    clear    and   notice   of   it   has   been

appropriately provided, the claims administrator's decision will

be upheld unless it is arbitrary, capricious, or an abuse of

discretion.      See Colby v. Union Sec. Ins. Co. & Mgmt. Co. for

Merrimack Anesth. Assocs. LTD Plan, 705 F.3d 58, 61 (1st Cir.

2013).

            The court below concluded that the Plan contained an

adequate grant of discretionary decisionmaking authority and,

therefore, its review of the claims administrator's decision to

deny benefits should be for abuse of discretion. The court offered

                                  - 13 -
twin rationales in support of its conclusion.    First, it held that

the Certificate alone contained a sufficiently clear grant of

discretionary authority to BCBS.        See Stephanie C., 2015 WL

1443012, at *7 (quoting the Certificate).         Second, the court

posited that the Certificate could be read in combination with the

PAA,   which   admittedly    provides   an   unambiguous    grant   of

discretionary authority to the claims administrator.          See id.

(quoting the PAA).

          Stephanie disputes both branches of this reasoning.       She

argues that the language of the Certificate is insufficiently

distinct to comprise a clear grant of discretionary authority.

She further argues that the PAA was never disclosed when coverage

attached and that, therefore, it cannot be used to clarify the

less-than-pellucid   grant    of   authority    contained    in     the

Certificate.

          The district court's determination of the applicable

standard of review is a matter of law and, thus, engenders de novo

review.   See United States v. Howard (In re Extrad. of Howard),

996 F.2d 1320, 1327 (1st Cir. 1993).    The key question is whether

the Plan "reflect[s] a clear grant of discretionary authority to

determine eligibility for benefits."     Leahy v. Raytheon Co., 315

F.3d 11, 15 (1st Cir. 2002).       In answering that question, "we

review the language of the Plan de novo, just as we would review

                               - 14 -
the language of any contract."      Ramsey v. Hercules Inc., 77 F.3d

199, 205 (7th Cir. 1996).

          The    principal   language    to   which    both   BCBS   and    the

district court advert in support of their shared conclusion that

the Plan confers a clear grant of discretionary decisionmaking

authority is contained in the Certificate.            In this respect, the

Certificate states that BCBS "decides which health care services

and supplies that you receive (or you are planning to receive) are

medically necessary and appropriate for coverage."             The power to

decide, they say, necessarily implies the existence of discretion.

          In our view, the quoted language simply cannot carry the

weight that BCBS and the district court load upon it.                      That

language merely restates the obvious: that no benefits will be

paid if BCBS determines they are not due.         See Diaz, 424 F.3d at

637-38 (noting that "[a]ll plans require an administrator first to

determine whether a participant is entitled to benefits before

paying them").

          Clarity of language is crucial to accomplishing a grant

of discretionary authority under an ERISA plan, and the Certificate

lacks that degree of clarity.           Under our case law, the "BCBS

decides" language falls well short of what is needed for a clear

grant of discretionary authority.        See Gross, 734 F.3d at 15-16;

see also Herzberger v. Standard Ins. Co., 205 F.3d 327, 331 (7th

Cir. 2000).   Put bluntly, the quoted language is not sufficiently

                                 - 15 -
clear to give notice to either a plan participant or covered

beneficiary that the claims administrator enjoys discretion in

interpreting and applying plan provisions.

              To be sure, "no precise words [in the Plan] are required"

to grant discretionary decisionmaking authority.                          Gross, 734 F.3d

at 15-16.       But in this regard, the Plan "must offer more than

subtle inferences."         Id. at 16.        Here, the inference of discretion

is subtle at best: it is merely one of two equally plausible

inferences that a reader might draw from the "BCBS decides"

language.

              The   short   of     it    is    that     a    grant    of   discretionary

decisionmaking authority in an ERISA plan must be couched in terms

that unambiguously indicate that the claims administrator has

discretion to construe the terms of the plan and determine whether

benefits are due in particular instances.                            See id. at 15-16;

Feibusch v. Integrated Device Tech., Inc. Emp. Benefit Plan, 463

F.3d 880, 884 (9th Cir. 2006); Kinstler v. First Reliance Standard

Life Ins. Co., 181 F.3d 243, 252 (2d Cir. 1999).                          The phraseology

that   BCBS    chose   to    use    in       the     Certificate      to    describe   its

decisionmaking       authority      is      capable     of    supporting       reasonable

differences of opinion as to the nature and extent of the authority

reserved to BCBS.       A fortiori, that phraseology is insufficiently

distinct      to    constitute          a     clear     grant        of     discretionary

decisionmaking authority.               See Gross, 734 F.3d at 13-15 (holding

                                            - 16 -
formulation "[p]roof [of claim] must be satisfactory to [claims

administrator]" insufficient to confer discretionary authority);

Heasley v. Belden & Blake Corp., 2 F.3d 1249, 1254-56 (3d Cir.

1993)       (holding   formulation      that    claims    administrator         "will

evaluate      the   proposed   admission       for   certification    of   medical

necessity" similarly insufficient).

              Contrary    to   BCBS's    importunings,       the     PAA   is    not

available to cure the ambiguity contained in the Certificate.

There is simply no evidence that the PAA was ever disclosed either

to Stephanie or to M.G.'s father when coverage attached.3                         Any

terms       that    concern    the   relationship        between     the    claims

administrator and the beneficiaries cannot be held against the

beneficiaries where, as here, the terms appear in a financing

arrangement between the employer and the claims administrator that

was never seasonably disseminated to the beneficiaries against

whom enforcement is sought.             See Fritcher v. Health Care Serv.

Corp., 301 F.3d 811, 817 (7th Cir. 2002).                Consequently, the PAA

        3
       In its brief, BCBS suggests that Stephanie should have been
on notice of the PAA because of references to the PAA contained in
the Certificate. But that suggestion is a non-sequitur: Stephanie
had no obligation to go in search of undelivered documents in order
to ascertain whether BCBS had reserved for itself discretionary
decisionmaking authority. See Helwig v. Kelsey-Hayes Co., 93 F.3d
243, 249 (6th Cir. 1996) (explaining that the critical
consideration "is the language actually given to the employees and
upon which they could reasonably have relied").

                                     - 17 -
cannot be used against Stephanie to bring clarity to an ambiguously

worded grant of decisionmaking authority.4    See Alday v. Container

Corp. of Am., 906 F.2d 660, 665-66 (11th Cir. 1990).

           That ends this aspect of the matter.     We hold that the

Certificate is ambiguous as to whether or not the Plan confers

discretionary decisionmaking authority upon BCBS.    We further hold

that, in the circumstances of this case, the undelivered PAA cannot

be employed to resolve this ambiguity.       Thus, the default rule

applies.   See Firestone, 489 U.S. at 115.     Under that rule, the

claims administrator's decision should have engendered de novo

review.    See id.   Because the district court looked at BCBS's

partial denial of benefits through the wrong standard-of-review

lens, we must vacate that portion of its judgment and remand for

reconsideration.

     4 With narrow exceptions not relevant here, see, e.g., Senior
Exec. Benefit Plan Participants v. New Valley Corp. (In re New
Valley Corp.), 89 F.3d 143, 149-50 (3d Cir. 1996) (allowing use of
bargaining history and conduct of parties to shed light on meaning
of plan terms), the practice is to look within plan documents to
clarify infirmities in plan language. See Bland v. Fiatallis N.
Am., Inc., 401 F.3d 779, 784-86 (7th Cir. 2005); Gridley v.
Cleveland Pneumatic Co., 924 F.2d 1310, 1312-14, 1316-17 (3d Cir.
1991); Alday v. Container Corp. of Am., 906 F.2d 660, 665-66 (11th
Cir. 1990). This appeal, however, does not require us to decide
whether the PAA is a plan document. Nor does it require us to
decide whether due notice of a reservation of discretionary
decisionmaking authority can be effected only through the Plan
itself.

                              - 18 -
III.   CONCLUSION

           We need go no further. For the reasons elucidated above,

we affirm the judgment of the district court in part, vacate that

judgment in part, and remand for further proceedings consistent

with this opinion.   No costs.

So Ordered.

                                 - 19 -