Doe v. Blue Shield of California, No. 3:2021cv02138 - Document 52 (N.D. Cal. 2022)
Court Description: OPINION AND ORDER. Signed by Chief Judge Richard Seeborg on 8/8/2022. (rslc3, COURT STAFF) (Filed on 8/8/2022)
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1 2 3 4 5 6 7 UNITED STATES DISTRICT COURT 8 NORTHERN DISTRICT OF CALIFORNIA 9 JANE DOE, et al., 10 Case No. 21-cv-02138-RS Plaintiffs, 11 United States District Court Northern District of California v. OPINION AND ORDER 12 BLUE SHIELD OF CALIFORNIA, 13 Defendant. 14 15 I. Introduction 16 17 In this action averring violations of the Employee Retirement Income Security Act of 1974 18 (“ERISA”), Plaintiff John Doe seeks mental health benefits for his daughter Jane Doe’s residential 19 treatment under an employee benefit plan (“Plan”) administered by Defendant California 20 Physicians’ Service dba Blue Shield of California (“Blue Shield”). Jane received benefits for four 21 weeks of care for her eating disorder at a residential treatment program, but Blue Shield decided 22 that residential treatment was no longer medically necessary at the conclusion of that four week 23 period, and instead recommended a day treatment program. Reviewing for abuse of discretion, 24 Blue Shield’s denial was unreasonable, and judgment will be granted in favor of Plaintiffs.1 This 25 decision, however, only covers the denial of benefits between January 7, 2021 and January 18, 26 2021—the period assessed in Blue Shield’s decision—and thus the period following January 18, 27 28 1 The administrative motions to file materials under seal, see Dkt. Nos. 41, 43, are granted. 1 2021 is remanded for determination of benefits by the administrator. This Opinion and Order 2 comprises the findings of fact and conclusions of law required by Federal Rule of Civil Procedure 3 52(a). 4 United States District Court Northern District of California 5 II. Factual Background In 2020, Jane was a 22-year-old college student who had struggled with anorexia nervosa 6 since her senior year of high school. She also suffered from severe anxiety (including panic 7 attacks) and obsessive-compulsive disorder (“OCD”). She previously received treatment in 8 intensive outpatient, partial hospitalization, and inpatient hospitalization settings, and had prior 9 instances of self-harm and suicidal thoughts. On December 10, 2020, Jane was admitted to 10 residential treatment at Avalon Hills Treatment Center (“Avalon”), an in-network provider with 11 Blue Shield. Her diagnoses at the time were anorexia nervosa, generalized anxiety disorder, panic 12 disorder, and OCD. Blue Shield approved benefits from December 10, 2020 to January 6, 2021. 13 On January 6, 2021, a peer review phone call was held between Jane’s treatment team at 14 Avalon and Blue Shield’s physician. On January 8, 2021, Blue Shield issued a letter denying 15 approval for residential care at Avalon from January 7, 2021 forward. On January 19, 2021, 16 Avalon submitted a written expedited appeal with treatment records and letters of support from 17 Jane’s treatment team. In a five-page letter, Jane’s therapist Amanda Willett wrote, among other 18 observations, that “[Jane] CANNOT manage the most basic person need, eating” and that “[Jane] 19 is very clear that if left to herself, she would return to restrictive eating.” AR 349. In a two-page 20 letter, nurse practitioner Chad Speth detailed Jane’s ongoing symptoms, concluding that he was 21 “concerned that were she to be treated at a lower level of care that there is a high likelihood of 22 relapse with potential associated morbidity and/or mortality.” AR 352. Blue Shield denied this 23 grievance on January 22, 2021. In its letter denying the appeal, Blue Shield noted that Jane’s 24 appeal “was looked at by an independent psychiatrist who agrees that care at a residential program 25 from January 7, 2021 and going forward, is not medically necessary, and [Jane] could have safely 26 27 OPINION AND ORDER CASE NO. 21-cv-02138-RS 28 2 1 been treated in a daytime only program.”2 Administrative Record (“AR”) 398. The letter provided 2 much of the same basis for denial as the January 7 letter, and explained as follows: 3 The most appropriate level of care for your ongoing care is treatment only during the daytime (partial hospitalization program, also called IOP). You can safely spend your nights and weekends away from Avalon Hills Adult Health Care. You were not a danger to yourself or others. You were cooperative in your treatment. You did not need care 24 hours per day. It was not likely that treatment only during the daytime (PHP) instead of treatment 24 hours per day would increase your chance of getting worse (relapse). 4 5 6 7 8 Id. Jane remained in residential treatment at Avalon until July 31, 2021, with Plaintiffs paying out of pocket for Jane’s residential care. 9 III. Legal Standard 10 United States District Court Northern District of California 11 12 13 14 15 16 17 18 19 20 21 The parties dispute the applicable standard of review. Plaintiffs argue that de novo review applies; Defendant argues that abuse of discretion review applies. “[A] denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo standard 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). “That means the default is that the administrator has no discretion, and the administrator has to show that the plan gives it discretionary authority in order to get any judicial deference to its decision.” Kearney v. Standard Ins. Co., 175 F.3d 1084, 1089 (9th Cir. 1999). The parties do not dispute that the relevant plan document states the administrator has discretion to interpret the plan; instead, Plaintiff argues that California law prohibits the kind of discretionary language present in the plan, citing language in California Insurance Code § 10110.6(a) which states that “[i]f a policy. . . that provides or funds life insurance or disability insurance coverage 22 for any California resident contains a provision that reserves discretionary authority to the insurer . 23 24 25 26 27 The letter also explained that “A Blue Shield Medical Director who is a California licensed physician and board certified in Obstetrics and Gynecology reviewed your request. In addition, your case was reviewed by a physician who is board certified in Psychiatry.” AR 398. The letter did not specify, however, whether opinions from these doctors were considered in reaching the determination, or how they were considered. 2 OPINION AND ORDER CASE NO. 21-cv-02138-RS 28 3 1 United States District Court Northern District of California 2 . . to interpret the terms of the policy . . . that provision is void and unenforceable.” Defendant argues that section 10110.6 applies only to health insurance policies, not 3 managed health care plans like the plan at issue here. As Defendant explains, Blue Shield is a 4 health care service plan subject to the Knox-Keene Act and regulated by the Department of 5 Managed Health Care (“DMHC”), see Hailey v. Cal. Physicians’ Serv., 158 Cal. App. 4th 452, 6 460-63 (2007), and a plan regulated by the DMHC is not subject to the Insurance Code or the 7 California Department of Insurance’s rules and regulations. See Cal. Ins. Code § 791.02(k) 8 (“’Insurance institution’ shall not include . . . health care service plans regulated pursuant to the 9 Knox-Keene Health Care Service Plan Act[.]”). As Defendant points out, other courts have 10 recognized that California law treats health insurance policies different than health care service 11 plans. See, e.g. Namdy Consulting, Inc. v. UnitedHealthcare Ins. Co., No. CV 18-01283-RSWL- 12 KS, 2018 WL 6430119, at *3 (C.D. Cal. July 11, 2018) (“[T]he Legislature has elected to subject 13 insurers and health care service plans to distinct regulatory regimes. Insurers are regulated by the 14 Insurance Code and the Insurance Commissioner. Health care service plans fall under the 15 jurisdiction of the Department of Managed Care and the Knox-Keene Act.” (quoting Smith v. 16 PacifiCare Behavioral Health of Cal., Inc., 93 Cal. App. 4th 139, 159 (2001)). 17 Further, Defendant points out that California recently enacted a corollary of the prohibition 18 in California Insurance Code § 10110.6 that explicitly applies to health care service plans. 19 California Health & Safety Code § 1367.045(a) provides that “[i]f a health care service plan 20 contract . . . contains a provision that reserves discretionary authority to the plan, or an agent of the 21 plan, to determine eligibility for benefits or coverage, to interpret the terms of the contract, or to 22 provide standards of interpretation or review that are inconsistent with the laws of this state, that 23 provision is void and unenforceable.” This section, which concerns health care service plans, is 24 applicable to Blue Shield. The statute, however, only applies to contracts “offered, issued, 25 delivered, amended, or renewed on or after January 1, 2021.” Cal. Health & Safety Code § 26 1367.045(a). The Plan in this case was issued on October 1, 2020. Given the clear language about 27 the effective date of the statute, there is no indication that the legislature intended for California OPINION AND ORDER CASE NO. 21-cv-02138-RS 28 4 1 Health & Safety Code § 1367.045(a) to apply retroactively. Section 1367.045(a) therefore does not 2 apply to the plan, and the standard of review is abuse of discretion. 3 4 circumstances in evaluating the decision of the plan administrator.” Pac. Shores Hosp. v. United 5 Behav. Health, 764 F.3d 1030, 1041 (9th Cir. 2014). Review for abuse of discretion requires 6 assessing whether the administrator’s decisions was “(1) illogical, (2) implausible, or (3) without 7 support in inferences that may be drawn from the facts in the record.” Salomaa v. Honda Long 8 Term Disability Plan, 642 F.3d 666, 676 (9th Cir. 2011) (internal quotation marks and citation 9 omitted). The court may “weigh[] a conflict of interest as a factor in abuse of discretion review.” 10 United States District Court Northern District of California “In reviewing for abuse of discretion, [the court] consider[s] all of the relevant Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 968 (9th Cir. 2006) (en banc). 11 IV. Discussion 12 For a multitude of reasons, Blue Shield abused its discretion in its denial of further 13 residential care for Jane. First, the denial letter was barebones. Although the letter indicated that 14 Blue Shield used the Level of Care Utilization System (“LOCUS”) guidelines in reaching its 15 determination, it failed to discuss any parts of the record or even mention evidence Jane and her 16 treatment team submitted on her behalf. It provided no basis for its conclusions such that Jane was 17 “not a danger” to herself or others and that Jane was “cooperative” in her treatment. AR 398. The 18 only reference to any evidence that Blue Shield chose to credit was the sentence that “your appeal 19 was also looked at by an independent psychiatrist who agrees that care at a residential program 20 from January 7, 2021 and going forward, is not medically necessary, and you could have safely 21 been treated in a daytime only program.” Id. Blue Shield’s denial letter is a recitation of 22 conclusions, with next to no information about how it arrived at those conclusions. 23 What regulations controlling the denial of benefits “call[] for is a meaningful dialogue 24 between ERISA plan administrators and their beneficiaries.” Booton v. Lockheed Med. Ben. Plan, 25 110 F.3d 1461, 1463 (9th Cir. 1997). “If benefits are denied in whole or in part, the reason for the 26 denial must be stated in reasonably clear language, with specific reference to the plan provisions 27 that form the basis for the denial[.]” Id. Blue Shield’s denial letter was not in any way a OPINION AND ORDER CASE NO. 21-cv-02138-RS 28 5 United States District Court Northern District of California 1 meaningful dialogue. The review of an appeal must take[] into account all comments, documents, 2 records, and other information submitted by the claimant relating to the claim[.]” 29 C.F.R. § 3 2560.503-1(h)(iv). Further, a plan administrator “may not arbitrarily refuse to credit a claimant’s 4 reliable evidence[.]” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 831 (2003). By not 5 even mentioning any of the evidence Jane submitted, Blue Shield arbitrarily refused to credit that 6 evidence. Had Blue Shield discussed the evidence, perhaps it could have provided reasons for 7 discounting or disregarding that evidence. Instead, Blue Shield apparently chose to “ma[ke] its 8 decision blindfolded[.]” Booton, 110 F.3d at 1463. Other district courts, including ones conducting 9 an abuse of discretion review, have rejected denials of benefits when the explanation is so 10 barebones that it is unclear what the administrator considered or how it weighted the evidence. 11 D.K. v. United Behav. Health, No. 2:17-CV-01328-DAK, 2021 WL 2554109, at *11 (D. Utah 12 June 22, 2021), appeal dismissed, No. 21-4112, 2021 WL 7543628 (10th Cir. Sept. 22, 2021) 13 (“[T]he denial letters similarly do not contain any specific citation to the medical record 14 whatsoever. Instead, the denial letters simply contain general statements about A.K.’s condition on 15 admission and minimal statements about her treatment while at Discovery.”); Scott M. v. Blue 16 Cross & Blue Shield of Mass., 528 F. Supp. 3d 1200, 1219-20 (D. Utah 2021), appeal dismissed, 17 No. 21-4053, 2021 WL 8154930 (10th Cir. Aug. 27, 2021) (rejecting administrator’s rationale 18 when it “only prepared conclusory statements that [claimant]’s ‘clinical condition does not meet 19 the medical necessity criteria required for acute psychiatric inpatient stay in the area of immediate 20 safety risk’”). 21 Relatedly, in issuing a barebones denial letter, Blue Shield ignored the opinions of Jane’s 22 treatment team. Although ERISA does not require administrators to “accord special deference to 23 the opinions of treating physicians[,]” plan administrators “may not arbitrarily refuse to credit a 24 claimant’s reliable evidence, including the opinions of a treating physician.” Nord, 538 U.S. at 25 831, 834. As a court in the District of Utah explained, when the plan administrator “neither 26 referred to [the treating physician]’s report, nor indicated that [the plan administrator] had either 27 considered the report or made contact with [the physician] to resolve any concerns[,]” the failure OPINION AND ORDER CASE NO. 21-cv-02138-RS 28 6 1 to address the letter from the physician “was violative of ERISA procedural safeguards.” Scott M., 2 528 F. Supp. 3d at 1219. Here, the denial letter fails even to mention the opinions of the treatment 3 providers, and thus provides no basis to ignore their opinions. 4 Next, parts of the denial letter appear contradicted by the record, without any effort to 5 discount the evidence that contradicts the conclusions in the letter. The denial letter tells Jane 6 “[y]ou were not a danger to yourself or others.” The letter from Willett, Jane’s primary therapist at 7 Avalon, tells a different story. In the January 14 letter, Willett explains as follows: 8 9 10 United States District Court Northern District of California 11 [Jane] is experiencing a recent increase in her suicidal thoughts, which are brought about during meals and snacks and exacerbated by her thoughts and feelings that she is losing the control she sought through the eating disorder, leaving her feeling helpless . . . [Jane] also experiences self-harm thoughts and has engaged in self-harm, while in care. While [Jane] is able to currently contract for safety, [] she reports that she is unsure if she can manage her suicidal and self-harm urges consistently. 12 13 AR 348. Willett’s observations are also supported by the treatment notes. For example, in a 14 therapy progress note from January 11, 2021, Willett noted that “[Jane] worries that her suicidal 15 thoughts will ‘take over her’ and she will not be able to control herself from acting on them.” AR 16 281. On January 18, Willett noted that the prior week “[Jane] self-harmed through scratching 17 (without breaking skin) in order to ‘numb out’ from her emotions.” AR 278. Defendant is correct 18 that suicidal thoughts and ideations, as well as thoughts and behaviors of self-harm, fall on a 19 spectrum. See Josef K. v. California Physicians’ Serv., 477 F. Supp. 3d 886, 900-901 (N.D. Cal. 20 2020) (noting that while “any mention of suicide from an adolescent may be troubling[,]” a plan 21 administrator did not abuse its discretion in concluding a patient did not have suicidal ideations 22 despite past remarks concerning suicide because “suicidal ideations, like many other conditions, 23 fall on a spectrum”). Blue Shield, however, did not explain why these reports from Willett were 24 not concerning—it simply ignored them. 25 The reviewers Blue Shield ostensibly relied upon in reaching its conclusions also appeared 26 to ignore record evidence, because some of their conclusions were directly contradicted by 27 information provided by Jane’s treatment team. For example, in assessing the LOCUS score, for OPINION AND ORDER CASE NO. 21-cv-02138-RS 28 7 United States District Court Northern District of California 1 category V – treatment and recovery history – the AMR reviewer noted that Jane was “fully 2 responsive to treatment and recovery management” and “[t]here was no indication that the patient 3 had any prior treatment that was unsuccessful in managing her symptoms.” AR 412. This 4 statement stands in stark contrast to Jane’s prior treatment history. As Blue Shield described 5 Jane’s prior treatment history in its own notes from a call with Avalon, Jane has a “4-year history 6 of [eating disorder] with anxiety and OCD that has no history of restoration.” AR 139. Avalon’s 7 therapist intake assessment described how in the years since she developed the eating disorder, 8 Jane had cycled in and out of both inpatient and outpatient programs, but had never been able to 9 reach the weight recommended by her outpatient physician. AR 265. Further, the Advanced 10 Medical Reviews (“AMR”) assessment—which was referred on January 20, 2021 and completed 11 the following day—stated “[t]here was no indication that the patient had ongoing suicidal or 12 homicidal ideations[.]” AR 411. Although the review purportedly concerned Jane’s status on 13 January 7, and it is not clear that Jane’s suicidal ideations had resumed before that date, the AMR 14 assessment of Jane’s safety was outdated in light of the reports her treatment team submitted on 15 appeal. 16 Draped over this entire landscape of errors and omissions is Blue Shield’s conflict. “What 17 the district court is doing in an ERISA benefits denial case is making something akin to a 18 credibility determination about the insurance company’s or plan administrator's reason for denying 19 coverage under a particular plan and a particular set of medical and other records.” Abatie, 458 20 F.3d at 969. Here, “the plan administrator faces a structural conflict of interest: since it is also the 21 insurer, benefits are paid out of the administrator's own pocket, so by denying benefits, the 22 administrator retains money for itself.” Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623, 23 630 (9th Cir. 2009). In this instance, Blue Shield provided minimal analysis, ignored record 24 evidence, and even contradicted information provided by the treatment team without any attempt 25 at explanation. Given the structural conflict, these errors are weighed even more heavily. 26 27 Considering “all of the relevant circumstances[,]” Pacific Shores Hospital, 764 F.3d at 1041, Blue Shield abused its discretion in denying residential treatment for the period from OPINION AND ORDER CASE NO. 21-cv-02138-RS 28 8 1 January 7, 2021 to January 18, 2021. The decision was both “illogical” and “without support in 2 inferences that may be drawn from the facts in the record.” Salomaa, 642 F.3d at 676. United States District Court Northern District of California 3 V. Remedy 4 “The Ninth Circuit has indicated that, if a decision to deny benefits is found unreasonable, 5 then a ‘court can either remand the case to the [plan] administrator for a renewed evaluation of the 6 claimant's case, or it can award a retroactive reinstatement of benefits.’” Bain v. Oxford Health 7 Ins. Inc., No. 15-CV-03305-EMC, 2020 WL 808236, at *11 (N.D. Cal. Feb. 14, 2020) (quoting 8 Demer v. IBM Corp. LTD Plan, 835 F.3d 893, 907 (9th Cir. 2016)). “[A] plan administrator will 9 not get a second bite at the apple when its first decision was simply contrary to the facts.” Grosz- 10 Salomon v. Paul Revere Life Ins. Co., 237 F.3d 1154, 1163 (9th Cir. 2001). There is no reason 11 here why Blue Shield should be given a second bite at the apple. For the period that Blue Shield 12 considered when denying coverage, the evidence consistently points towards the need for 13 continued residential care. Jane experienced a return of suicidal thoughts. While she had made 14 some progress in treatment, she expected to return to limiting meals and snacks if she returned 15 home. Prior treatment, in both residential and outpatient settings, had limited success. As noted by 16 the American Psychiatric Association Guidelines, “[p]atients with inadequate motivation or 17 support who are discharged from inpatient to partial hospitalization programs before they are 18 clinically ready often have high rates of early relapse, greater struggles with recovery, and slower 19 rates of progress, necessitating longer future inpatient stays.” Rachel S. v. Life & Health Benefits 20 Plan of the Am. Red Cross, No. 2:14-CV-778, 2020 WL 6204402, at *3 (D. Utah Oct. 22, 2020). 21 Blue Shield’s decision, however, only addressed the period between January 7, 2021 and 22 January 18, 2021, and did not consider evidence beyond that time. Jane stayed at Avalon receiving 23 residential care through July 2021. Courts may remand to the plan administrator to make factual 24 determinations of unresolved issues. See Mongeluzo v. Baxter Travenol Long Term Disability Ben. 25 Plan, 46 F.3d 938, 944 (9th Cir. 1995) (permitting “remand to the plan administrator for an initial 26 factual determination”); see also Carrier v. Aetna Life Ins. Co., 116 F. Supp. 3d 1067, 1084 (C.D. 27 Cal. 2015) (remanding to the plan administrator when “there [was] nothing in the Administrative OPINION AND ORDER CASE NO. 21-cv-02138-RS 28 9 United States District Court Northern District of California 1 Record for the Court to resolve [a] factual issue”). The question of whether any benefits are due 2 for the period of residential care between January 19, 2021 and July 31, 2021 is therefore 3 remanded to the administrator for determination of whether any portion of that period should have 4 been covered by the Plan. 5 Finally, Plaintiffs bring a claim for equitable relief under 29 U.S.C. § 1132(a)(3). Plaintiffs 6 do not address this claim in their Opening Trial Brief. In the Responding Trial Brief, Plaintiffs clarify 7 that they “seek equitable relief in the manner of a remand to Blue Shield regarding residential 8 treatment for dates of service from January 19, 2021 to Jane’s discharge on July 30, 2021.” Plaintiffs’ 9 Responsive Trial Brief, p.23. As explained above, remand is warranted as the plan administrator did 10 not make a factual determination as to the period after January 18, 2021. Although it is unclear 11 whether this is properly fashioned as “equitable relief” or simply the required course of action in the 12 absence of a factual determination, remand is appropriate for the period after January 18, 2021. 13 The Court will retain jurisdiction over this matter until the review on remand is completed. 14 Although the absence of information in the record about Jane’s condition after January 2021 means the 15 Court takes no position on whether a further award of benefits is warranted, Blue Shield is warned to 16 provide a fuller explanation of any denial of benefits, if it decides to deny benefits for any further 17 period. Following the conclusion of Blue Shield’s review on remand, the parties are directed to request 18 a case management conference should further proceedings before this Court be necessary. If no further 19 proceedings are needed, the parties are directed to provide a joint statement so stating, and judgment 20 will be entered at that time. VI. Conclusion 21 22 For all the foregoing reasons, the Court concludes that Blue Shield abused its discretion in 23 denying coverage for residential treatment for the period between January 7, 2021 and January 18, 24 2021, and benefits are awarded for that time period. The matter is remanded to the administrator 25 for the determination of whether benefits are due for any period between January 19, 2021 and 26 July 31, 2021 under the Plan. 27 OPINION AND ORDER CASE NO. 21-cv-02138-RS 28 10 1 IT IS SO ORDERED. 2 3 4 5 Dated: August 8, 2022 ______________________________________ RICHARD SEEBORG Chief United States District Judge 6 7 8 9 10 United States District Court Northern District of California 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 OPINION AND ORDER CASE NO. 21-cv-02138-RS 28 11
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