I. M. v. Kaiser Foundation Health Plan ( 2020 )

NOT FOR PUBLICATION FILED
UNITED STATES COURT OF APPEALS DEC 22 2020
MOLLY C. DWYER, CLERK
U.S. COURT OF APPEALS
FOR THE NINTH CIRCUIT
I. M., on behalf of himself and all others No. 19-16374
similarly situated,
D.C. No. 4:17-cv-02475-JSW
Plaintiff-Appellant,
v. MEMORANDUM*
KAISER FOUNDATION HEALTH PLAN,
INC.,
Defendant-Appellee.
Appeal from the United States District Court
for the Northern District of California
Jeffrey S. White, District Judge, Presiding
Argued and Submitted October 20, 2020
San Francisco, California
Before: THOMAS, Chief Judge, and KELLY** and MILLER, Circuit Judges.
This putative class action case arises out of a health insurance dispute
between I.M. and Kaiser Foundation Health Plan, Inc. (“KFHP”). I.M. alleges that
KFHP breached its fiduciary duties owed under the Employee Retirement Income
*
This disposition is not appropriate for publication and is not precedent
except as provided by Ninth Circuit Rule 36-3.
**
The Honorable Paul J. Kelly, Jr., United States Circuit Judge for the
U.S. Court of Appeals for the Tenth Circuit, sitting by designation.
Security Act of 1974 (“ERISA”), 29 U.S.C. § 1104(a)(1), by excluding residential
treatment programs from its plan and by failing to provide adequate procedures
that would enable providers to refer eating disorder patients to residential treatment
programs. The district court granted summary judgment in favor of KFHP and
denied reconsideration. I ER 1–10. On appeal, I.M. contends that the district court
overlooked numerous factual disputes concerning whether KFHP breached its
fiduciary duties concerning medically necessary residential treatment. I.M. further
contends that there is no support in the record that I.M. turned down help in getting
residential treatment and instead opted for private-pay out-of-network residential
treatment. This latter proposition is plainly incorrect. We have jurisdiction under
28 U.S.C. § 1291 and we affirm.
STANDARD OF REVIEW
Summary judgment is appropriate “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). We review the district court’s grant of
summary judgment de novo, construing the facts in the light most favorable to the
nonmoving party. Santopietro v. Howell, 857 F.3d 980, 987 (9th Cir. 2017).
However, “[r]ulings regarding evidence made in the context of summary judgment
are reviewed for an abuse of discretion.” Wong v. Regents of Univ. of Cal., 410
F.3d 1052, 1060 (9th Cir. 2005).
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DISCUSSION
Because the parties are familiar with the facts and procedural background,
we need not restate them here. “ERISA protects employee pensions and other
benefits by providing insurance . . . , specifying certain plan characteristics in
detail . . . , and by setting forth certain general fiduciary duties applicable to the
management of both pension and nonpension benefit plans.” Varity Corp. v.
Howe, 516 U.S. 489, 496 (1996). One of ERISA’s basic purposes is to protect
participants and beneficiaries “by establishing standards of conduct, responsibility,
and obligation for fiduciaries,” and “providing for appropriate remedies . . . and
ready access to the Federal courts.” Id. at 513 (quoting ERISA § 2(b), 29 U.S.C. §
1001(b)). Under ERISA, a beneficiary may bring a civil action “(A) to enjoin any
act or practice which violates any provision of this subchapter or the terms of the
plan, or (B) to obtain other appropriate equitable relief (i) to redress such violations
or (ii) to enforce any provisions of this subchapter or the terms of the plan.”
ERISA § 502(a)(3), 29 U.S.C. § 1132(a)(3).
I.M. asserts a breach of fiduciary duty under § 1132(a)(3), and therefore
must show “both (1) that there is a remediable wrong, i.e., that the plaintiff seeks
relief to redress a violation of ERISA or the terms of a plan; and (2) that the relief
sought is ‘appropriate equitable relief.’” Gabriel v. Alaska Elec. Pension Fund,
773 F.3d 945, 954 (9th Cir. 2014) (internal citations omitted). I.M. fails to
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establish the first element; thus, the district court properly granted summary
judgment in favor of KFHP.
I.M. contends that KFHP breached its fiduciary duty by improperly
excluding residential treatment for eating disorders from its plan. However, I.M.’s
own course of treatment belies this argument. I.M. spent five days at the Center
for Discovery — a residential treatment facility — before checking himself out
against medical advice. Other than his own declaration, there is no indication that
this treatment was approved as a special, one-time circumstance. Rather, the
evidence and what actually occurred indicates that treatment at the Center for
Discovery was plainly covered in his plan. Undisputed evidence shows that KFHP
covered residential treatment, that it had contracts with residential treatment
centers to provide in-network options, and that it had a referral system to allow for
approval of out-of-network care when necessary. See, e.g., IV ER 422–23, 430–
31; see also II ER 61 (I.M.’s Kaiser plan). I.M. fails to rebut this evidence, relying
only on the speculation of one social worker at Herrick hospital who believed
Kaiser would not cover additional residential care. II ER 37. This is not enough to
defeat summary judgment. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242,
249–50 (1986) (“If the evidence is merely colorable, or is not significantly
probative, summary judgment may be granted.”) (internal citations omitted). The
statement is not one of KFHP and plainly is not a denial of benefits.
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Despite his plan’s coverage, I.M. repeatedly refused to take advantage of
KFHP’s residential treatment options, instead opting for a private, out-of-network
facility. Although I.M. argues that he never turned down in-network residential
treatment, the record proves that he repeatedly told his doctors that he planned to
pursue out-of-network residential options. See, e.g., III ER 316, 341, 352; IV ER
565, 583, 594, 607–08.
Furthermore, I.M.’s reliance on Harlick v. Blue Shield of Cal., 686 F.3d 699(9th Cir. 2012), is misplaced. Harlick addressed a denial of benefits claim, id. at
707, while, notably, I.M. abandoned his denial of benefits claim after it was
dismissed for failure to exhaust administrative remedies. The plan at issue in
Harlick also expressly excluded residential treatment programs. Id. at 709.
Although I.M.’s plan has some limiting language, it did not expressly exclude all
residential treatment for the treatment of eating disorders and it is undisputed that
I.M.’s residential treatment was covered. Thus, I.M.’s argument that his plan
excluded residential treatment fails.
I.M. also argues that KFHP breached its fiduciary duty by failing to provide
procedures that would enable providers to refer patients with eating disorders to
residential treatment. As evidence of this, I.M. points to his providers’ confusion
about when and how to make such referrals.
Simply put, there is no evidence that KFHP’s procedures (or lack thereof)
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inhibited I.M. from obtaining residential treatment. Indeed, Dr. Rau, I.M.’s
therapist, testified that she would refer patients for residential treatment through
KFHP’s system and had developed a process for doing so. IV ER 523; SER 150–
51, 157–58. Instead, it was I.M. who either refused to consider residential
treatment or would only consider out-of-network programs when the option was
raised. III ER 316, 341, 352; IV ER 565, 583, 594, 607. Once I.M. decided on
residential treatment, he and his mother solicited Dr. Rau’s opinion on various out-
of-network options and updated Dr. Rau about his progress. IV ER 555–57, 569,
574–75, 579–80, 583, 587, 590–91, 594, 607–08. Just because Dr. Rau did not
directly refer patients to residential programs does not make her ignorant of the
referral process nor does it create a factual dispute. Likewise, that Dr. Rau did not
know of other in-network residential facilities other than the Center for Discovery
does not create a genuine issue of material fact. See Anderson, 477 U.S. at 249–
50. Dr. Rau knew how to refer patients with eating disorders, but it was I.M.’s
own statements that stopped her from going through that process. Ultimately, the
record belies any argument that KFHP erected barriers to residential treatment and,
in fact, KFHP left treatment decisions in the exclusive control of I.M.’s providers.
I.M.’s argument concerning his doctor’s confusion about an alleged “fail
first” policy also fails to establish a breach of fiduciary duty. The confusion arose
out of a communication between Dr. Hazlett, I.M.’s psychiatrist, and Dr. Wang, a
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doctor at a psychiatry call center. IV ER 474; SER 200. Dr. Wang informed Dr.
Hazlett that in order for I.M. to be hospitalized, he must first fail an eating disorder
intensive outpatient program evaluation. Not only was this communication about
hospitalization — as opposed to residential treatment — but there is no evidence
that such a policy was ever applied to I.M. Mere confusion about how to obtain
hospitalization in one instance is not adequate grounds for finding a breach of
fiduciary duty under ERISA concerning residential treatment.
Finally, it is important to note that administrators like KFHP cannot be held
vicariously liable for its providers’ medical judgments. See Watanabe v. Cal.
Physicians’ Serv., 169 Cal. App. 4th 56, 68 (Cal. Ct. App. 2008) (“[H]ealth care
services plans ‘are not health care providers under any provision of law’ ([Cal. Civ.
Code § 3428(c)]) and therefore cannot be liable for medical malpractice.”).
Although this issue does not apply to I.M.’s allegations regarding KFHP’s policies
and procedures, I.M. appears to try and graft his dissatisfaction with his doctors’
course of treatment onto KFHP. His doctors are not KFHP employees, but instead
are employed by an affiliated company, the Permanente Medical Group.
Therefore, I.M. may not attribute the alleged deficiencies of his doctors to KFHP.
Accordingly, the district court did not err in granting summary judgment in
favor of KFHP.
AFFIRMED.
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