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Kessler v. Aetna Health Inc.

United States District Court, D. Delaware

April 16, 2015



RICHARD G. ANDREWS, District Judge.

Presently before the Court is Defendant's motion for summary judgment and an award of attorney's fees. (D.I. 10).

I. Background

Plaintiff, Brian Kessler, was admitted to inpatient treatment at Father Martin's Ashley for drug and alcohol addiction on April 16, 2013. (D.I. 18 at 272). He was subsequently discharged on May 14, 2013. ( Id. ) After Defendant, Aetna, denied coverage for the inpatient treatment, Father Martin's Ashley filed an appeal with Aetna on June 11, 2013. ( Id. at 271). Aetna responded on July 19, 2013, denying the appeal in a letter signed by a medical doctor. ( Id. at 256-61). Aetna later modified its decision to cover the detox period of April 16, 2013 through April 18, 2013. ( Id. at 306). Aetna maintained the position that the period between April 19, 2013 and May 14, 2013 would not be covered on the basis that it was not "medically necessary." ( Id. ). On September 11, 2013 Plaintiff personally appealed Aetna's decision to deny coverage. ( Id. at 307). Aetna upheld the denial in a letter dated November 8, 2013. ( Id. at 310). Following the appeals process, Plaintiff filed a Request for External Review on December 13, 2013. ( Id. at 340). The External Review, authored by a board certified psychiatrist, upheld Aetna's decision to deny coverage. ( Id. at 322).

With no other opportunity to appeal through Aetna, Plaintiff filed a lawsuit in Delaware Superior Court on June 4, 2014. (D.I. 1, Ex. A). Defendant removed the case to this Court on July 16, 2014. (D.I. 1). On December 31, 2014, Defendant filed its motion for (1) summary judgment and (2) an award of attorney's fees. (D.I. 10). For the reasons provided below, Defendant's motion for summary judgment is granted and motion for attorney's fees is denied.

II. Summary Judgment

Pursuant to the Employee Retirement Income Security Act (BRISA), "participant[s] or beneficiar[ies]" may bring an action "to recover benefits due to him under the terms of his plan...." 29 U.S.C. § 1132 (a)(1)(B). "[A] denial of benefits challenged under §1132(a)(1)(B) is to be reviewed under a de nova 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). The Third Circuit has explained that" [w]hen the administrator has discretionary authority, we review only for abuse of that discretion." Howley v. Mellon Financial Corp., 625 F.3d 788, 792 (3d Cir. 2010). An abuse of discretion occurs if the decision "is without reason, unsupported by substantial evidence or erroneous as a matter of law." Id. (citation omitted).

Defendant argues that summary judgment is proper because, given the discretionary nature of the plan, Defendant did not abuse its discretion in denying the coverage. (D.I. 11 at 7). Furthermore, Defendant detailed its reasoning for denying coverage, and both a medical doctor and a complaint and appeal specialist reviewed the appeal. ( Id. at 8). Finally, Defendant argues that the external review is additional evidence that it did not abuse its discretion in denying coverage. ( Id. ).

Plaintiff contends that there is a question regarding how Aetna made its decision to deny coverage and what Aetna's reasoning was for doing so.[1] (D.I. 15 at 9). Plaintiff argues that Defendant disregarded Plaintiffs prior medical history, especially the fact that Plaintiff had failed to remain sober after a shorter stay at an inpatient facility. ( Id. at 9). Since Plaintiff has remained sober after this most recent treatment, Plaintiff concludes that inpatient treatment was in fact medically necessary. ( Id. ).

In this case, Plaintiff's insurance plan gave Defendant discretionary authority.[2] Therefore review is limited to whether Defendant abused that discretion. After reviewing the administrative record, I conclude that Defendant did not abuse its discretion in determining that the inpatient treatment from April 19, 2013 to May 14, 2013 was not medically necessary. First, Defendant provided its reasoning for denying coverage. In a letter dated November 8, 2013, a Complaint and Appeal Analyst explained: "[y]ou completed an uncomplicated detoxification prior to this admission. You have a history of two months clean time following residential treatment in 2012 but did not follow up with the intensive outpatient treatment and eventually relapsed." (D.I. 18 at 310-13). This explanation is especially relevant considering Defendant's position that Plaintiff should have attempted intensive outpatient treatment as the appropriate level of care. This letter goes on to explain, "ASAM criteria do not support residential treatment as the medically necessary level of care for the dates in question but do support partial hospitalization treatment. This decision was made using the ASAM." ( Id. ). There is no basis to argue that Defendant's decision was without reason.

At Plaintiff's request, Defendant used its entire appeals process, concluding with a third party upholding Defendant's determination. A third party's review is not dispositive, but it does tend to support the reasonableness of Defendant's determination.

Whether an intensive outpatient treatment would have been successful is unknown. That the inpatient program was successful is known. It does not follow, however, that an intensive outpatient treatment program should not have been considered. Plaintiff failed to follow up with that level of treatment in 2012 ( Id. at 312), but that did not mean that he was bound to fail given a second opportunity. More importantly, it was not unreasonable to conclude that the 2012 treatment was successful, and that the later relapse did not undermine the conclusion that a brief inpatient stay to detox was the medically necessary level of treatment.

Plaintiff offered no evidence of his own showing that Defendant's decision constituted an abuse of discretion. Considering the high standard that Plaintiff must meet for this Court to overturn the denial, the lack of an expert supporting Plaintiff's position makes it almost impossible to meet that standard. Summary judgment in favor of Defendant is thus proper. Defendant's decision to deny coverage was not ...

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