United States District Court, D. Minnesota
Mark A. Smith, Esq., Elizabeth I. Wrobel, Esq. and Wrobel & Smith, PLLP, counsel for plaintiff.
Patrick H. O'Neill, Jr., Esq. and Larson King, LLP, and Edna S. Kersting, Esq. and Wilson, Elser, Moskowitz, Edelman & Dicker, LLP, counsel for defendants.
DAVID S. DOTY, District Judge.
This matter is before the court upon the cross-motions for summary judgment by plaintiff Quinn Nystrom and by defendants AmerisourceBergen Drug Corporation (AmerisourceBergen), AmerisourceBergen Group Health and Welfare Plan (Plan No. 625) and Aetna Life Insurance Company (Aetna). Based on a review of the file, record and proceedings herein, and for the following reasons, the court grants the motion by defendants.
This insurance benefit dispute arises out of medical care received by Nystrom. Nystrom had health insurance through an insurance plan (Plan) provided by her former employer, AmerisourceBergen. AmerisourceBergen was the statutory administrator of the Plan. Admin. R. 86. Aetna was a third-party service provider and claims administrator for the Plan. Compl. ¶ 8.
Nystrom has been diagnosed with bulimia nervosa, posttraumatic stress disorder (PTSD), major depression, alcohol abuse and Type I diabetes. Admin. R. 137, 139, 292, 303. Throughout such diagnoses, Nystrom was treated in outpatient, inpatient and hospital settings. Id. at 139, 177, 179. In May 2012, Nystrom was admitted for inpatient eating disorder treatment at Methodist Hospital in Minnesota. Id. at 137-143. Nystrom remained hospitalized for one week. Id. at 141. Thereafter, Nystrom began intensive day programming at Melrose Institute while she was on a waiting list for Timberline Knolls Residential Treatment Center (Timberline Knolls), an eating disorder treatment center in Lemont, Illinois. Id. at 138.
On June 19, 2012, Nystrom was admitted to Timberline Knolls. Compl. ¶ 22; Admin. R. 185. On June 22, 2012, Timberline Knolls sought retroactive pre-certification from Aetna for residential treatment for Nystrom. Admin. R. 185-86. Aetna denied coverage, finding that "[t]reatment of [Nystrom] could be provided at a lower level of care, or in another setting, e.g., partial hospitalization, intensive outpatient, or routine outpatient" treatment. Id. at 181. The denial letter informed Nystrom that she could appeal the decision, and that she should include "comments, documents, records and other additional information you would like to have considered." Id. at 152.
Nystrom requested an expedited appeal. On June 26, 2012, Nystrom's treating psychiatrist, Dr. Lauren Kofod, participated in a telephonic appeal of the decision. Compl. ¶ 35. Two psychiatrists reviewed the claim and again denied coverage, finding Nystrom "does not... meet criteria for a residential level of care but does meet [criteria] for partial hospitalization treatment." Admin. R. 179. Nystrom again appealed the denial. Another psychiatrist reviewed the request for reconsideration and again denied coverage, finding that "[t]he need for the residential level of care has not been well presented.... Based on the information currently available, the patient appears to be able to be safely and effectively treated in a partial hospitalization level of care." Id. at 177.
On July 5, 2012, Nystrom requested an external review, and on July 10, 2012, the external reviewer upheld Aetna's denial of benefits. The external reviewer found that "[t]here is no evidence in the record that [Nystrom] requires residential level of care at this time." Id. at 129. On August 17, 2012, Nystrom was discharged into the partial hospitalization program at Timberline Knolls.
On March 11, 2013, Nystrom filed suit, alleging a claim under the Employee Retirement Income Security Act (ERISA). Nystrom and defendants both move for summary judgment.
I. Standard of Review
"The court shall grant summary judgment if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(a); see Celotex Corp. v. Catrett , 477 U.S. 317, 322 (1986). A fact is material only when its resolution affects the outcome of the case. Anderson v. Liberty Lobby, Inc. , 477 U.S. 242, 248 (1986). A dispute is genuine if the ...