Opinion
Civil Action No. 02-7686.
June 8, 2004
MEMORANDUM
Presently before the Court are Plaintiff's Motion for Summary Judgment and Defendants' response thereto, as well as, Defendants' Motion for Summary Judgment and Plaintiff's response thereto. For the reasons set forth below, Defendants' Motion is granted and Plaintiff's Motion is denied.
I. Background
The following facts are undisputed by the parties. While working as an accountant for Marriot International, Inc., Plaintiff Joel Grossman became severely impaired by bipolar disorder such that he could not work after June 2, 1999. Liberty Life Assurance Company of Boston ("Liberty Life") administered and funded the Long Term Disability insurance program ("LTD") sponsored by Marriott International, Inc. ("Marriott"), for the benefit of its employees and subsequent to Plaintiff's application for benefits, determined Plaintiff was fully disabled and began to pay benefits under the plan. The LTD plan administered by Liberty Life contains a provision terminating benefit payments for claims involving mental illness after 24 months. This mental illness limitation contains a waiver that extends payments past the 24 month limitation if the claimant is participating in an extended treatment program in lieu of hospitalization.
Over the two years following Plaintiff's initial claim for LTD benefits, Dr. Kenneth Nelson, Plaintiff's personal psychiatrist, diagnosed and treated Plaintiff for bipolar disorder, depression and memory impairment. Plaintiff's visits with Dr. Nelson occurred every three to four weeks throughout this time. Also during this two year period, Plaintiff submitted to four independent medical examinations ("IME") to substantiate his claim for benefits. All four IME physicians agreed Plaintiff suffered from bipolar disorder and that his affliction was so severe that he was unable to work. In September 1999, Plaintiff contacted Liberty Life to ask for a further explanation of what constituted "extended treatment." Liberty Life case manager Belinda Silva responded in January 2001 with a letter explaining that to satisfy the extended treatment in lieu of hospitalization requirement Plaintiff must be "participating in a day treatment program or be partially hospitalized." (Pl.'s Mot. for Summ. J. Ex. F at 2). This information was not explicitly stated within the policy, but rather was derived from Ms. Silva's discussions with Dr. Mirkin, a contract physician employed by Liberty Life to review mental health claims and determine the adequacy of any extended treatment claims.
On the advice of Dr. Nelson, Plaintiff entered a partial hospitalization program on June 18, 2001 and remained in that program until July 27, 2001. Liberty Life determined that this program qualified as extended treatment in lieu of hospitalization and paid benefits through July 27, 2001. After July 27, 2001, Liberty Life determined that Plaintiff's subsequent care did not qualify as extended treatment in lieu of hospitalization, and denied Plaintiff's request for continuing benefits. Plaintiff appealed this decision through the proper channels. All appeals were denied.
In a July 23, 2002 letter to Liberty Life, counsel for Plaintiff requested Liberty Life revisit its final appeal determination and offered new information concerning treatment provided on a daily basis by Plaintiff's spouse Ms. Leslie Gilman. Ms. Gilman is a heathcare professional with a Bachelors degree in psychology and a M.B.A in Health Administration. She works as a nursing home administrator, and since 1999 has served as the administrator of an adult day health program, which includes a unit for Alzheimer's patients. Plaintiff claims his wife has implemented a daily treatment regimen throughout his term of disability. This treatment includes monitoring and ensuring Plaintiff takes his medications, performing daily assessments of Plaintiff and providing this information to his treating physician, administering light therapy, instructing and monitoring his exercise activity program, adjusting therapy for agitation with deescalating techniques, and communicating with Plaintiff at least six or seven times per day or making frequent visits. (Pl.'s Mot. for Summ. J. at 12).
Liberty Life did not disturb its previous determination and the present action ensued.
II. Standard of Review
A motion for summary judgment will be granted where all of the evidence demonstrates "that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(c). A dispute about a material fact is genuine "if the evidence is such that a reasonable jury could return a verdict for the nonmoving party." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). Since a grant of summary judgment will deny a party its chance in court, all inferences must be drawn in the light most favorable to the party opposing the motion. U.S. v. Diebold, Inc., 369 U.S. 654, 655 (1962).
The ultimate question in determining whether a motion for summary judgment should be granted is "whether reasonable minds may differ as to the verdict." Schoonejongen v. Curtiss-Wright Corp., 143 F.3d 120, 129 (3d Cir. 1998). "Only disputes over facts that might affect the outcome of the suit under the governing law will properly preclude the entry of summary judgment." Anderson, 477 U.S. at 248.
III. Discussion
Before reviewing Defendant's decisions, the Court must first determine the appropriate standard for reviewing such decisions. The Supreme Court has held, "a denial of benefits . . . 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). If the benefits plan grants the administrator the discretion to determine eligibility benefits, then the court must review the administrator's decision using an arbitrary and capricious standard. Abnathya v. Hoffmann-La Roche, Inc., 2 F.3d 40, 41 (3d Cir. 1993). "Under the arbitrary and capricious standard, the court must defer to the administrator of an employee benefit plan unless the administrator's decision is clearly not supported by the evidence in the record or the administrator has failed to comply with the procedures required by the plan." Id.
Under certain circumstances, however, Courts must use a more stringent standard of review. Specifically, if an employer hires an insurance company to both fund and administer an employee benefits plan, then the insurance company "is generally acting under a conflict that warrants a heightened form of the arbitrary and capricious standard of review." Pinto v. Reliance Standard Life Ins. Co., 214 F.3d 377, 378 (3d Cir. 2000). It is the plaintiff's burden to prove that a conflict exists and that the court should use a heightened standard of review. Schlegel v. Life Ins. Co. of N. America, 269 F. Supp.2d 612, 617 (E.D. Pa. 2003); Scarinci v. Ciccia, 880 F. Supp. 359, 364 (E.D. Pa. 1995).
In the instant case, the parties do not dispute, and the evidence is clear that Liberty Life had the authority and discretion to determine eligibility benefits; therefore, the Court must use the arbitrary and capricious standard of review. Both parties agree, at least for the purposes of this motion, that because Liberty Life both administers and funds the benefits program that there is a conflict of interest sufficient to warrant the heightened arbitrary and capricious standard of review. (Pl.'s Mot. for Summ. J. at 4; Def.'s Mot. for Summ. J. at 13 n. 2).
Under ERISA the court must consider only that information available to the plan administrator during the claims review process. Michell v. Eastman Kodak Co., 113 F.3d 433, 440 (3d Cir. 1997). In this case, Liberty Life reviewed Plaintiff's medical records to determine if the treatment he received qualified as extended treatment in lieu of hospitalization. Those records included reports from various Independent Medical Examiners, and the notes from Plaintiff's treating physician Dr. Nelson, which indicated that Plaintiff's treatment was "in lieu of hospitalization." (Def.'s Mot. for Summ. J. at 16). Dr. Mirkin, the psychiatrist hired by Liberty Life to review Plaintiff's file, noted, however, that Dr. Nelson's treatment regimen lacked sufficient intensity to be considered "in lieu of hospitalization," (Def.'s Mot. for Summ. J. at 15), and was unsupported by "objective observations" that would support the "in lieu of hospitalization" determination. (Def.'s Mot. for Summ. J. at 16). Liberty Life did not consider, nor may the Court consider the treatment provided by Ms. Gilman, Plaintiff's wife, because the information regarding that treatment was not before the plan administrator when the final decision and subsequent appeals were made. On the basis of Plaintiff's medical records, this Court finds that even under the heightened arbitrary and capricious standard, there is no reasonable basis for overturning Liberty Life's decision to terminate benefits based on the 24 month mental illness limitation provision of the LTD plan and for the denial of further benefits under the extended treatment provision. Given the information known to Liberty Life at the time the decision was made, there was an objective and reasonable basis for Liberty Life to find that Plaintiff was not engaged in an extended treatment plan in lieu of hospitalization as required under the Plan for the continuation of benefits. Therefore, the Court grants Defendant's Motion for Summary Judgment and denies Plaintiff's Motion for Summary Judgement. An appropriate order follows.
Dr. Mirkin explained in a June 12, 2001 memorandum that Plaintiff's treatment plan under Dr. Nelson failed to qualify as treatment "in lieu of hospitalization" because:
Treatment that is considered in lieu of hospital confinement would be treatment that is the same as, or of similar intensity of care as that which would be delivered in a hospital setting. Such treatment, according to the APA guidelines listed above, would be delivered to someone lacking the capacity to cooperate without patient treatment or at risk for suicide or without adequate psychosocial supports. If these indicators of intensive care were found, it would be expected that Dr. Nelson would substantially change his relatively low frequency of outpatient care and do this to the point where he was seeing him frequently once or twice per week; or had ordered a visiting nurse to visit his home regularly to monitor his mental state and medication compliance; or had placed him in partial hospitalization program. These actions would reflect his concern for safety and functional capacity that would indicate that he was considering hospitalization and that his interventions were "in lieu of hospitalization." Clearly, this is not reflected in his outpatient care where the frequency and intensity of visits is low and did not change much in the ten months under review.
(Def.'s Mot. for Summ. J. Ex. Q).