Ho-Rath et al v. Tufts Associated Health Maintenance Organization, Inc., No. 1:2012cv00546 - Document 46 (D.R.I. 2013)
Court Description: OPINION AND ORDER: Defendants motion for summary judgment is GRANTED and Plaintiffs motion for summary judgment is DENIED. So Ordered by Judge William E. Smith on 10/31/2013. (Urizandi, Nisshy)
Download PDF
<![CDATA[
UNITED STATES DISTRICT COURT FOR THE DISTRICT OF RHODE ISLAND ___________________________________ ) ) ) ) ) ) Plaintiffs, ) ) v. ) ) TUFTS ASSOCIATED HEALTH ) MAINTENANCE ORGANIZATION,INC., ) ) Defendant. ) ___________________________________) JEAN HO-RATH, individually and p.p.a. Y.H., a minor; and BUNSAN HO-RATH, individually and p.p.a. Y.H., a minor, C.A. No. 12-546 S OPINION AND ORDER WILLIAM E. SMITH, United States District Judge. Plaintiffs individually, Jean and on and Bunsan behalf Ho-Rath of their brought minor this daughter action Y.H., (together the Ho-Raths or Plaintiffs ) to clarify and enforce the terms of their former health insurance plan, pursuant to the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. ( ERISA ). Before cross-motions for summary judgment. the Court are the parties For the reasons set forth below, Defendant s motion for summary judgment is GRANTED, and Plaintiffs motion for summary judgment is DENIED. I. Facts 1 For years, the Ho-Raths have admirably persevered trying to obtain a treatment that they believe will cure their daughter from a chronic and potentially deadly disease. At the age of five, doctors diagnosed Y.H. with Alpha Thalassemia Hemoglobin H Constant Springing ( Thalassemia ). Put very Thalassemia is a dangerous genetic blood disorder. simply, To treat this disease, now fifteen-year-old Y.H. undergoes frequent blood transfusions. As a result of these treatments, Y.H. suffers from complications with respect to her liver and spleen. Y.H. s doctors have indicated that her best chance for a cure is to undergo a bone marrow transplant using the umbilical cord stem cells of a sibling donor, who is a bone marrow match for Y.H., but who is not afflicted with Thalassemia. If conceived naturally, a new child born to the Ho-Raths has approximately a 19% chance of being a match with Y.H., but has a 25% chance of being afflicted with Thalassemia. As a result, the Ho-Raths have sought to begin a pregnancy through a complex procedure that would create a disease-free matched donor. 2 This procedure is in vitro fertilization ( IVF ) with 1 The facts are drawn from the ample administrative record, which accompanied these motions. These facts are not in dispute. 2 A sibling donor lowers the risks associated with this type of transplant to a mortality rate of less than 5%. The same 2 intraytoplasmic sperm injection ( ICSI ) and pre-implementation genetic testing leukocyte ( PGD ) antigen ( HLA ) to ensure bone a marrow disease-free, match for human Plaintiffs daughter. Defendant Tufts Associated Health Maintenance Organization ( Tufts or Defendant ) was the Ho-Raths health insurance provider during the time period relevant to this case. From 2007 to 2012, Tufts repeatedly denied Plaintiffs request for this complex procedure under Coverage (the Plan ). 3 2011, Maximus, the the Ho-Raths Evidence of In November 2010 and again in April independent appeals agent for the Rhode Island Department of Health ( DOH ), overturned these denials. The November testing and 2010 the ruling April testing and IVF. by 2011 Maximus permitted PGD with HLA decision permitted PGD with HLA Ultimately, following further review of the April 2011 decision, Maximus determined its decision on this appeal was incorrect and the DOH decided it should not have precedential value. procedure using a non-sibling donor results in a mortality rate of 20%. 3 The Ho-Raths withdrew from the Plan on August 31, 2012. Plaintiffs and Defendant argued vigorously about whether the HoRaths leaving the Plan forecloses any remedy. Because this Court finds that Defendant did not abuse its discretion in interpreting the Plan, it need not address this question. Jakobiec v. Merrill Lynch Life Ins. Co., 711 F.3d 217, 223 (1st Cir. 2013). 3 Still, Tufts paid for one round of IVF that resulted from Maximus s decision in April 2011. To date, Plaintiff Jean Ho- Rath has undergone five unsuccessful cycles of IVF, with most of these treatments paid for out of pocket by Plaintiffs and one round paid for by Defendant as a result of Maximus s decision. In July 2011, Plaintiffs made another request for coverage of the same procedure. Tufts asked for more information about the request from the Ho-Raths physicians, and when none was provided, Defendant denied the claim in September 2011. Raths appealed this decision. The Ho- Tufts and its peer review service examined this appeal and denied it, finding that Mrs. Ho-Rath did not have a diagnosis of infertility, and that PGD with HLA testing was specifically limited under the Plan. (AR-239.) 4 Ho-Raths took a second level appeal with similar results. The This time, Tufts and its peer review service denied the claim citing the earlier failed attempts at IVF and the peer review service s determination that Mrs. Ho-Rath s age and recent medical history suggested less than a 5% chance of success for a future round of IVF. (AR-312.) The Ho-Raths then appealed to Maximus. time Maximus denied Plaintiffs appeal in March 2012. This Maximus found that Mrs. Ho-Rath did not meet the Infertility Guidelines of the Plan because: 4 (1) she was infertile due to her age; (2) AR refers to the administrative record. 4 an additional round of IVF had a chance of success less than 5%; and (3) the prior failed IVF attempts precluded coverage. (AR- 741.) II. Standard of Review Both sides agree that the proper lens through which to view this dispute is whether denying Plaintiffs [w]hen an ERISA Defendant claim. plan This gives an abused its standard discretion of review administrator in applies discretionary authority to determine eligibility for benefits or construe the plan s terms. D&H Therapy Assocs., LLC v. Boston Mut. Life Ins. Co., 640 F.3d 27, 34 (1st Cir. 2011). Here, the Plan gives Tufts the discretionary authority to construe the terms of the [plan], to make factual determinations and to make final and binding decisions about eligibility and claims. The administrator s reading need (AR-1.) not be the best interpretation of the plan, nor come to the same conclusion the Court would if analyzing the plan on its own. F.3d at 35. D&H Therapy, 640 A benefit determination is within the discretion of the administrator as long as it is reasoned and supported by substantial evidence. Id. Evidence is substantial where it is reasonably sufficient to support a conclusion. Desrosiers v. Hartford Life & Acc. Ins. Co., 515 F.3d 87, 92 (1st Cir. 2008) (quoting Wright v. R.R. Donnelley & Plan, 402 F.3d 67, 74 (1st Cir. 2005)). 5 Dons Co. Group Benefits Where the administrator both pays benefits and determines eligibility for claims, as is the case here, the court must consider this inherent conflict of interest in applying the abuse of discretion standard. Denmark v. Liberty Life Assur. Co. of Boston, 566 F.3d 1, 9 (1st Cir. 2009) (holding that courts should review benefit-denial decisions for abuse of discretion, considering any conflict as one of a myriad of relevant factors ). This dual role is known as a structural conflict[] as opposed to a situation where a fiduciary s decision was in fact motivated by an actual conflict of interest. Id. at 5 n.2. Thus, Tufts s interpretation is afforded deference and should only be overturned if found to be an abuse of discretion, cognizant of the dual recognizing role being that the Court must played by Tufts and be the potential conflict this creates. III. Discussion A. Tufts s Interpretation of the Plan Plaintiffs present an extremely sympathetic case. The administrative record makes plain that for the last six years, Y.H. s repeated parents have coverage their daughter. Plaintiffs, carried denials, on in undeterred hopes of in obtaining the a face cure of for Irrespective of the sympathetic appeal of the however, the Court must remain mindful that the decision in this case revolves around contract interpretation. Because the insurance plan at issue affects the parties rights 6 under ERISA, it is interpreted in accordance with tenets of federal common law. Smart v. Gillette Co. Long-Term Disability Plan, 70 F.3d 173, 178 (1st Cir. 1995). Under this approach, unambiguous terms are construed in accordance with their plain and natural meaning. Chapman v. Supplemental Benefit Ret. Plan of LIN Television Corp., 723 F. Supp. 2d 485, 489 (D.R.I. 2010). Terms of a plan may be ambiguous where they are inconsistent on their face or phraseology can support reasonable differences of opinion as to the meaning of the words employed and the obligations undertaken. Id. (quoting Smart, 70 F.3d at 178). Even ambiguous, where a plan is proferentem does not construction advanced construe the plan. apply by an to the doctrine review of administrator an given of contra ERISA plan authority to D&H Therapy, 640 F.3d at 35. Tufts s interpretation of the Plan denying coverage for IVF and PGD with HLA typing is reasoned and supported by substantial evidence, and therefore Tufts did not abuse its discretion in reading the Plan. The Plan states that it will pay for COVERED SERVICES and supplies when they are MEDICALLY NECESSARY. 761.) (AR- Thus, the plain language dictates that the question of whether a service determinations medically that necessary. should a be approved procedure (Id.; see is also (1) hinges covered AR-802.) In on and both (2) pertinent part, the Plan defines covered services as those that are (1) 7 listed as covered services; (2) medically necessary; (3) consistent with state and federal law; and (4) consistent with Tufts s clinical guidelines in effect at the time services were requested. The caveat (AR-776.) Plan that lists IVF IVF as procedures a covered will service, only be SERVICES for MEMBERS with infertility. further clarifies this position by but with considered (AR-780.) stating the COVERED The Plan specifically that fertility services are excluded for those members who do not meet the definition of infertility. (AR-803.) The Plan s Infertility Guideline further articulates the requirements for IVF services. This Guideline requires: (1) a diagnosis of infertility; (2) a demonstrated likelihood of success defined as a live birth rate of at least 5%; (3) infertility must be caused by disease rather than age; and (4) for each IVF cycle that has previously been attempted at least successfully transferred to the uterus. Through appeal, Tufts including: of two rounds denied of internal Plaintiffs three embryos were (AR-281-83.) appeals claim for and one outside several reasons (1) that Mrs. Ho-Rath did not meet the requirement infertility based on disease; (2) that Mrs. Ho-Rath was infertile due to age; and (3) that unsuccessful prior attempts 8 at IVF precluded coverage. 5 All of these rationales are reasoned and supported by substantial evidence. allege that Mrs. Ho-Rath is Indeed, Plaintiffs never infertile otherwise meets the Plan guidelines. 6 based on disease or Therefore, the denial of IVF by Tufts was not an abuse of discretion. Eligibility determinations for PGD are made separately from decisions about IVF. (AR-294.) Approval for PGD service does not necessarily mean a member will be approved for IVF service. (AR-294.) The PGD Guideline provides for PGD determinations with respect to identifying whether an embryo is afflicted with Thalassemia. (A-295.) In addition, the Plan permits HLA typing to determine if two people are a bone marrow match. But the PGD Guideline purpose of HLA typing. not cover (AR-782.) expressly does PGD for the (AR-295.) Plaintiffs argue that PGD for the purpose of HLA typing is based on scientific evidence, and should be NECESSARY permitted to include because the services Plan and defines MEDICALLY interventions widespread use, as based on scientific evidence. not in (AR-828.) 5 During a hearing on the cross-motions for summary judgment, Plaintiffs noted that the appeal denial letter from Maximus states that Plaintiff Jean Ho-Rath is now infertile. Maximus made this infertility determination based on age. The Infertility Guideline requires a diagnosis of infertility to be based on disease, not age, to be eligible for IVF procedures. 6 In fact, Plaintiffs admit Mrs. Ho-Rath does not meet these infertility requirements. (Pls. Mem. in Supp. of Their Objection and Cross-Mot. for Summ. J. 13.) 9 Even were the Court to agree with Plaintiffs that PGD for the purpose of HLA could be deemed medically necessary, PGD services are not permitted for this purpose applying the plain language of the PGD Guideline. Plaintiffs have requested this service for the exact reason not permitted by the Plan, and thus denial of this service was not an abuse of discretion by Tufts. B. Tufts s Case Management Procedures Next, Plaintiffs argue that Tufts abused its discretion in failing to include Y.H. in two discretionary case management programs. management In its programs Plan, - Tufts Individual Special Case Management ( SCM ). established Case two special Management ( ICM ) case and Plaintiffs try to establish an entitlement under the Plan s SCM and ICM programs, and argue that by not including Y.H. in these programs, Tufts showed its abuse of discretion. This argument also fails. The SCM provides that some MEMBERS with Severe Illnesses or Injuries may warrant case management intervention under our specialty case management program. (AR-769.) Plaintiffs suggest some underhanded purpose in the fact that this program was included in order for Tufts to manage its own costs. Plaintiffs, however, ignore the plain terms of the plan which provide that only COVERED SERVICES were permitted under the SCM. (AR-769.) As discussed in Section III. A., supra, IVF was not a covered service under this Plan and these circumstances, 10 and thus Tufts did not abuse its discretion by not including Y.H. in the SCM program. Tufts members with a severe eligible for a different program. illness or injury may be The ICM program was designed to arrange for the most appropriate type, level, and setting of health care services and supplies. (AR-770.) Under the program, non-covered services that are less costly than covered services may sometimes be available. non-covered Defendant services are readily available in admits an that ICM, but correctly notes that the non-covered service must be provided directly to the MEMBER with the condition. (AR-770.) is other no question that, while the IVF and There procedures requested were for Y.H. s benefit, they would not be provided directly to her, but instead would be provided to her mother. Therefore, Tufts s decision not to include Y.H. in the ICM program does not suggest an abuse of discretion. C. Tufts Discussions with the Department of Health Plaintiffs argue that Tufts impermissibly spoke to the DOH following the second instance where Maximus Defendant s decision on appeal in April 2011. Plaintiffs Tufts s allege, abuse of had a chilling discretion. The effect, facts overturned This interaction, which evidences surrounding the communication between Tufts and DOH dispel any notion that Tufts acted inappropriately. 11 The letter from Maximus to the Ho-Raths stating they had been successful in their appeal contains a sentence inviting them to call DOH if they had any questions. (AR-526.) Tufts was carbon copied on the letter, and read it as suggesting that it too could call DOH with any questions. called the DOH and left a message. 4, ECF No. 45-2). A Tufts employee (Decl. of Libby Hanrahan ¶ DOH eventually returned this message and requested a conference call with Tufts. (Id. at ¶ 5.) During that call, DOH revealed that it had asked Maximus to conduct a quality review of the Ho-Raths case, and that after doing so, Maximus agreed its reviewer had not applied the Plan coverage criteria as required by state law. (Id.) There is no evidence that Tufts attempted to improperly influence the DOH or Maximus in coming to this decision. Thus, this interaction simply does not establish that Tufts abused its discretion in handling the Ho-Rath case. D. Res Judicata Finally, Plaintiffs argue that the November 2010 and April 2011 decisions by Maximus should have res judicata effect. This argument, raised for the first time in a supplemental memorandum of law filed just days before a hearing on the cross-motions for summary judgment, is unpersuasive. Decisions of administrative appeals agents may have res judicata effect. See Schoen v. Presbyterian Health Plan, Inc., Nos. Civ. 08-0687 JOB/WDS, 0812 0970 JOB/WDS, 2009 WL 1299680, at *9 (D.N.M. Feb. 19, 2009). The November 2010 decision by Maximus has no bearing on the question of IVF, because it only involved PGD. (AR-610-12.) The April 2011 decision was the subject of review by DOH and an internal quality control review by Maximus as discussed supra in Section III. C. After this review revealed that Maximus had not based its decision on all of the elements required for external review, the DOH determined that this decision would not be precedential for future benefits determinations in the Ho-Raths case. (Pls. Mem. in Supp. of Their Objection and Cross-Mot. for Summ. J., Ex. 32.) Thus, the decision simply has no bearing on the dispute currently before the Court. Even if the earlier decision was precedential, Plaintiffs would not succeed with this argument. Res judicata operates to bar the relitigation of issues that were or could have been raised in an earlier action between the same parties prescinding from the same set of operative facts. Carvalho v. Fed. Nat l Mortg. Ass n (In re Carvalho), 335 F.3d 45, 49 (1st Cir. 2003). This case does not flow from the same operative facts as the earlier decisions by Maximus. The Plan requires that requests for IVF be reviewed anew each time, taking into account the success of the prior attempt and the likelihood an IVF treatment would be successful. certain level of If a prior attempt fails to achieve a success, a new 13 round of IVF will not be approved, according Guideline. to the (AR-281-83.) clear Here, terms the of denial the of Infertility the Ho-Raths request was premised in part on failed earlier IVF attempts and the belief that age and other factors made the likelihood of success less impact than 5%. Plaintiffs consideration of Were attach earlier would be nullities. to Maximus s it, attempts decision to the requirements and likelihood have the regarding of success Because this denial represents a distinct set of operative facts, res judicata does not bind this Court s determination. IV. Conclusion For the reasons stated above, Defendant s motion for summary judgment is GRANTED and Plaintiffs motion for summary judgment is DENIED. IT IS SO ORDERED. /s/ William E. Smith William E. Smith United States District Judge Date: October 31, 2013 14
]]>
Some case metadata and case summaries were written with the help of AI, which can produce inaccuracies. You
should read the full case before relying on it for legal research purposes.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
