Doe v. Harvard Pilgrim Health Care

United States Court of Appeals
For the First Circuit
No. 19-1879
JANE DOE,
Plaintiff, Appellant,
v.
HARVARD PILGRIM HEALTH CARE, INC.; THE HARVARD PILGRIM PPO PLAN
MASSACHUSETTS, GROUP POLICY NUMBER 0588660000,
Defendants, Appellees.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MASSACHUSETTS
[Hon. Denise J. Casper, U.S. District Judge]
Before
Torruella, Selya, and Kayatta,
Circuit Judges.
Mala M. Rafik, with whom Sarah E. Burns and Rosenfeld & Rafik,
P.C. were on brief, for appellant.
Steven L. Schreckinger, with whom Jane M. Guevremont and
Anderson & Kreiger LLP were on brief, for appellees.
September 9, 2020
KAYATTA, Circuit Judge. Jane Doe spent several months
of 2013 at a residential mental health treatment center,
interrupted by several days in an inpatient hospital in June of
that year. The Defendants ("Harvard Pilgrim") agreed to cover the
costs of Doe's treatment at the residential facility, the Austen
Riggs Center ("Riggs") in Massachusetts, for her first few weeks
there, as well as the months after her stint in an inpatient unit.
However, Harvard Pilgrim denied coverage for the time period from
February 13, 2013, through June 18, 2013, asserting that Doe could
have stepped down to a lower level of treatment during those
months. Doe sued Harvard Pilgrim in the District of Massachusetts
seeking de novo review of her claim for coverage of that time
period under the Employee Retirement Income Security Act
("ERISA"), 29 U.S.C. §§ 1001–1461. Following an earlier appeal,
the district court entered judgment for Harvard Pilgrim on remand.
Doe now appeals both that judgement and the district court's
refusal to award Doe attorneys' fees for her success on the prior
appeal. For the following reasons, we affirm the district court's
rulings.
I.
Our previous opinion in this case reviewed in detail the
events giving rise to this litigation. See Doe v. Harvard Pilgrim
Health Care, Inc., 904 F.3d 1, 2–6 (1st Cir. 2018) (Doe I). For
the purposes of this appeal, we set out a short summary of the
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relevant facts here: Doe began experiencing serious symptoms of
psychological illness during her first year of college in 2012 and
was hospitalized twice over the course of a few months. On
January 17, 2013, Doe was admitted to Riggs. Harvard Pilgrim
approved initial coverage of her treatment there for seven days.
Harvard Pilgrim eventually extended Doe's coverage through
February 5, but on that date sent Doe a letter stating that her
treatment at Riggs would not be covered as of February 6. Doe
initiated an expedited internal review of the decision, which
Harvard Pilgrim denied on February 12, 2013, based on a report by
Dr. Michael Bennett. Harvard Pilgrim accepted coverage through
February 12, and otherwise stood by its denial. Subsequently, on
March 12, 2013, an anonymous, independent expert retained by the
Massachusetts Office of Patient Protection ("OPP") also upheld
Harvard Pilgrim's denial of coverage for a continued stay at Riggs,
albeit beginning as of February 13, not February 6.
During the course of these reviews, Doe remained at Riggs
for treatment. On June 18, however, Doe was transferred from Riggs
to inpatient treatment at Berkshire Medical Center. She was then
readmitted to Riggs from Berkshire Medical Center on June 24.
Although Harvard Pilgrim initially denied coverage for Doe's
second admission to Riggs (beginning on June 24, 2013), it reversed
that decision after an internal review by Dr. Edward Darell
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concluded that the second admission was medically necessary. Doe
was finally released from Riggs on August 7, 2013.
Doe filed this case against Harvard Pilgrim in March
2015. Harvard Pilgrim's Medical Director, Dr. Joel Rubenstein,
conducted another review in September 2015 and concluded that
Harvard Pilgrim had properly denied coverage. Harvard Pilgrim
then agreed to reconsider that decision. Doe I, 904 F.3d at 4, 9.
That reconsideration generated further information and medical
opinions, including two offered by Doe (by Drs. Gregory Harris and
Eric Plakun), all of which Harvard Pilgrim reviewed as the parties
agreed. Id. at 4. After Harvard Pilgrim reaffirmed its decision
denying coverage for the time period at issue, the parties filed
cross-motions for summary judgment. Id. at 5. The district court
restricted its review to the administrative record as of March 12,
2013, and therefore did not consider records generated or exchanged
during Harvard Pilgrim's reconsideration of its denial. See Doe
v. Harvard Pilgrim Health Care, Inc., No. 15-10672, 2017 WL
4540961, at *10–11 (D. Mass. Oct. 11, 2017). Ultimately, the
district court agreed with Harvard Pilgrim and entered summary
judgment dismissing Doe's claim. See id. at *15. On Doe's appeal,
we vacated the judgment, ruling that the district court should
include in the record and consider the additional material
generated as a result of Harvard Pilgrim's agreement to conduct a
supplemental review of additional information, as well as other
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information produced in the interim (letters from Doe's treating
psychologist, Dr. Sharon Krikorian, and documents relating to
Doe's second admission, including a report from Dr. Edward
Darell). Doe I, 904 F.3d at 4, 6–9, 11. We also clarified that,
in the event of a second appeal, we would review the district
court's factual findings only for clear error. Id. at 9–11. On
remand, the district court again granted summary judgment for
Harvard Pilgrim, and Doe now appeals a second time.
II.
A.
1.
As we explained previously, "[i]n the ERISA context,
'the burdens and presumptions normally attendant to summary
judgment practice do not apply.'" Doe I, 904 F.3d at 10
(alteration omitted) (quoting Stephanie C. v. Blue Cross Blue
Shield of Mass. HMO Blue, Inc., 813 F.3d 420, 425 n.2 (1st Cir.
2016) (Stephanie C. I)). Instead, a summary judgment motion in a
lawsuit contesting the denial of benefits under ERISA "is simply
a vehicle for teeing up the case for decision on the administrative
record." Id. (citing Doe v. Standard Ins. Co., 852 F.3d 118, 123
n.3 (1st Cir. 2017)). Unless discretionary authority has been
granted to the plan administrator, the district court considers
the issues de novo and "may weigh the facts, resolve conflicts in
evidence, and draw reasonable inferences." Stephanie C. v. Blue
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Cross Blue Shield of Mass. HMO Blue, Inc., 852 F.3d 105, 111 (1st
Cir. 2017) (Stephanie C. II) (citing Orndorf v. Paul Revere Life
Ins. Co., 404 F.3d 510, 518 (1st Cir. 2005)). Thus, "summary
judgment in the ERISA context is akin to judgment following a bench
trial in the typical civil case." Doe I, 904 F.3d at 10–11. As
a result, we review the district court's factual findings for clear
error. Id. at 11.
2.
Doe's family's plan from Harvard Pilgrim provides
coverage only for treatment that is "medically necessary." The
plan defines "medically necessary" treatment as:
Those health care services that are consistent
with generally accepted principles of
professional medical practice as determined by
whether: (a) the service is the most
appropriate supply or level of service for the
Member's condition, considering the potential
benefit and harm to the individual; (b) the
service is known to be effective, based on
scientific evidence, professional standards
and expert opinion, in improving health
outcomes; and, (c) for services and
interventions that are not widely used, the
service for the Member's condition is based on
scientific evidence.
To determine medical necessity in the context of mental
health treatment, Harvard Pilgrim employs the Optum Level of Care
Guidelines from United Behavioral Health ("the Guidelines").
Under the Guidelines, residential treatment is defined as
"provid[ing] overnight mental health services to members who do
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not require 24-hour nursing care and monitoring offered in an acute
inpatient setting but who do require 24-hour structure." The
parties agree that Riggs provides such residential treatment. In
order for such treatment to be medically necessary, the plan member
must meet one of the three following criteria:
1. The member is experiencing a disturbance in
mood, affect or cognition resulting in
behavior that cannot be safely managed in a
less restrictive setting. - OR -
2. There is an imminent risk that severe,
multiple and/or complex psychosocial
stressors will produce significant enough
distress or impairment in psychological,
social, occupational/educational, or other
important areas of functioning to undermine
treatment in a lower level of care. - OR -
3. The member has a co-occurring medical
disorder or substance use disorder which
complicates treatment of the presenting mental
health condition to the extent that treatment
in a Residential Treatment Center is
necessary.
No party argues that Doe met the third criterion; instead, Doe
maintains that she qualified for residential treatment under the
first two criteria. The district court -- like Harvard Pilgrim
-- found that Doe did not meet either of the first two criteria as
of February 13, 2013.1
1 For continued care after initial approval, the Guidelines
require -- among other things -- that "[t]he criteria [listed
above] for the current level of care continue to be met" and "[t]he
member's current symptoms and/or history provide evidence that
relapse or a significant deterioration in functioning would be
imminent if the member was transitioned to a lower level of care."
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Doe's overarching argument on appeal is that the expert
reports that formed the basis for Harvard Pilgrim's denials of
coverage improperly used an incorrect standard of care,
essentially requiring that she need 24-hour nursing care, even
though the Guidelines state explicitly that residential treatment
should be available "to members who do not require 24-hour nursing
care and monitoring offered in an acute inpatient setting but who
do require 24-hour structure." Specifically, the OPP reviewer
justified his or her decision based on finding "no evidence that
the patient required 24 hour supervision or nursing care," and Dr.
Rubenstein's report similarly repeatedly references "24 hour care"
as the relevant benchmark without mentioning the Guideline's
language of "24-hour structure." (The only other expert in the
record to conclude that the first admission was not necessary after
February 13, 2013, Dr. Bennett, did not reference the Guideline
language at all.)
We disagree with Doe: It was not clear error for the
district court to rely on these reports despite their references
to "24-hour care." To begin, it was hardly error for the experts
to cite the lack of any need for round-the-clock care in the first
place. The experts would have erred only if they opined that a
Because we uphold the district court's decision that the standard
for the current level of care was not met as of February 13, it
follows that the criteria for continued care were not met at that
point.
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need to receive such care was necessary to qualify for the
coverage. The district court did not commit clear error in opting
not to read the expert reports in that manner. The OPP report in
particular based its conclusion on a finding that Doe did not need
"24 hour supervision or nursing care" (emphasis added).
More generally, when read in context, the references to
24-hour care can be understood as referring to the availability of
such care as provided by Riggs. Thus, even Doe's own expert,
Dr. Harris, referred to Doe's repeated accessing of 24-hour
nursing care during the night, presumably intending to say only
that Doe needed nursing care to be available around the clock, not
that she needed care to be actively provided for 24 hours each
day. The district court's opinion can then be read to explain
that Doe did not require 24-hour "structure" either. For example,
the district court considered the length and frequency of Doe's
trips away from Riggs (totaling nearly twenty days away) and the
ways in which she utilized the services that were available to her
there and concluded that all Doe needed was a system in which she
could access nursing care each day to arrange a plan for safely
managing her symptoms at night if necessary. Although Doe argues
that the district court should not have assumed Doe would have
that ability at a lower level of care, she has not developed the
record on why a partial hospitalization program would have been
insufficient.
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Doe's further arguments are similarly unavailing given
the clear error standard of review. Although Doe argues that the
district court should have drawn different inferences from facts
including her difficulty with interpersonal relationships inside
and outside Riggs, her difficult but perhaps supportive
relationship with her family, her ability to ask for and access
the services she needed at Riggs, the "casual" tenor of her
interactions with nursing staff, and her ability to spend time
away from Riggs for recreation and other personal reasons during
her admission, we do not believe the district court clearly erred
in making the inferences that it did, many of which were supported
by the Bennett and Rubenstein reports. Nor do we fault the
district court for relying on evidence that Doe's condition had
stabilized on medication leading up to the February 13 date. While
Doe's condition obviously deteriorated at some point after that,
it was not clear error for the district court to conclude that, at
least at that point, her continued stay at Riggs was not medically
necessary.
Finally, Doe complains that the district court accepted
the opinions of Harvard Pilgrim’s experts "without weighing their
conclusions against the weight of the record." We disagree. The
district court clearly reviewed the record as a whole, drawing
inferences from both the facts and the expert opinions. We find
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no clear error in the fact that the district court implicitly
agreed more with Harvard Pilgrim's experts than with Doe's.
B.
We turn now to Doe's argument that the district court
erred in the manner in which it conducted the proceedings on
remand.2 The district court treated as comprising the record
everything compiled by or submitted to Harvard Pilgrim in the
course of making its final coverage decision, as we ordered in
Doe I, 904 F.3d at 9. It then allowed the parties to submit
extensive written argument directed to that record. Finally, it
held oral argument and issued a decision.
In so proceeding, the district court did exactly what
the law called for. Judicial review of a benefits denial under 29
U.S.C. § 1132(a)(1)(B) takes the form of a review of "final ERISA
2 Harvard Pilgrim -- viewing Doe's argument specifically as
an argument for a Rule 52 bench trial on the papers -- maintains
that Doe has waived the argument, because she neither sought a
Rule 52 bench trial explicitly before the appeal to this court in
Doe I, nor on remand. Instead, on remand she moved for an
evidentiary hearing with witnesses. To the extent Doe is
requesting a bench trial without additional witness testimony,
that argument fails, too. She has not explained how such a bench
trial on the papers would be different from the de novo review the
district court conducted. See Doe I, 904 F.3d at 10–11 (explaining
that "summary judgment in the ERISA context is akin to judgment
following a bench trial in the typical civil case"). At oral
argument, she posited that the district court might have given
counsel more opportunity to make their arguments if it had been
conducting a Rule 52 bench trial. But of course a district court
always has the option to conduct oral argument on summary judgment
motions (as it did here) -- how much time is allotted for that
purpose is up to the district court in either situation.
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administrative decision." Id. at 6 (quoting Orndorf, 404 F.3d at
519). As such, we presume -- absent some very good reason to do
otherwise -- that the record is limited to the record compiled by
and submitted to the administrative decisionmaker leading up to
and including its final administrative decision. Id. (citing
Liston v. UNUM Corp. Officer Severance Plan, 330 F.3d 19, 23 (1st
Cir. 2003) ("[A]t least some very good reason is needed to overcome
the strong presumption that the record on review is limited to the
record before the administrator.")).
Doe offers no good reason for why the district court
should not have proceeded in accord with this "strong presumption"
against supplementing the administrative record. Liston, 330 F.3d
at 23. The case presents no claim that Harvard Pilgrim's process
of decision-making was unlawful or that the administrator
exhibited a conflict of interest. Nor does Doe claim that
materials were improperly omitted from the record on remand, or
that the district court did not comply with our decision in
defining the record to be reviewed.
Instead, Doe simply argues that she would have preferred
that the various experts testify and be subject to cross-
examination, as if this were an insurance coverage dispute under
state law, rather than judicial review of an administrator's
benefit decision under ERISA. That is an argument that we long
ago rejected. Orndorf, 404 F.3d at 519 (explaining that judicial
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review does not "warrant calling as witnesses those persons whose
opinions and diagnosis or expert testimony and reports are in the
administrative record").
Doe argues that we should not rely on Orndorf here
because Orndorf employed a standard of appellate review that has
since been rejected in this Circuit. See Doe I, 904 F.3d at 9–10
(explaining the difference in appellate standards of review used
in prior circuit cases). But Orndorf's description of the record
to be reviewed by the district court did not hinge on its
definition of the standard of review on appeal. Rather, as Doe I
explains, we have consistently held that the record before the
district court should match the record reviewed by the
administrative decisionmaker absent some special circumstance.
Id., 904 F.3d at 6 (applying Orndorf and Liston to determine the
scope of the record despite our move to a clear error standard of
review).
C.
Finally, Doe appeals the district court's denial of her
request for attorneys' fees and costs resulting from the litigation
of the case up through our decision in Doe I. ERISA allows a court
"in its discretion [to] allow a reasonable attorney's fee and costs
of action to either party." 29 U.S.C. § 1132(g)(1). A court may
award fees whenever a party has showed "some degree of success on
the merits." Hardt v. Reliance Standard Life Ins. Co., 560 U.S.
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242, 245 (2010) (quoting Ruckelshaus v. Sierra Club, 463 U.S. 680,
694 (1983)); see Gastronomical Workers Union Loc. 610 & Metro.
Hotel Ass'n Pension Fund v. Dorado Beach Hotel Corp., 617 F.3d 54,
66 (1st Cir. 2010). Such a result must be more than a "trivial
success" or "purely procedural victor[y]." Hardt, 560 U.S. at 255
(alteration in original) (quoting Ruckelshaus, 463 U.S. at 688
n.9); see Gastronomical Workers, 617 F.3d at 66 (requiring a
"merits outcome [that] produces some meaningful benefit for the
fee-seeker").
Doe argues that our previous remand to the district court
defining the scope of the record and clarifying the clear error
standard of review made her eligible for attorneys' fees under
ERISA. In so arguing, she relies primarily on Gross v. Sun Life
Assurance Co. of Can., 763 F.3d 73 (1st Cir. 2014). In Gross,
instead of reviewing a district court's denial of fees, we decided
the claimant's eligibility for fees in the first instance and
remitted to the district court to decide the appropriate amount.
Id. at 75, 81. We reasoned that an ERISA claimant was eligible
for fees where we had previously remanded to the district court
with instructions to remand to the plan administrator for a new
review of the claim. Id. at 77–78.
We need not decide, however, whether Doe's win in Doe I
makes her eligible for attorneys' fees under ERISA. That is
because the district court alternatively held that "[e]ven
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assuming arguendo that Hardt and Gross apply and Jane is eligible
for an award of attorneys' fees . . . such award is not warranted
here." The standard guiding the district court's discretion in
this analysis is set out in Cottrill v. Sparrow, Johnson & Ursillo,
Inc., 100 F.3d 220, 225 (1st Cir. 1996). See Gross, 763 F.3d at
82 ("Although the Supreme Court in Hardt emphasized that the multi-
factor tests traditionally used by courts to decide whether to
award fees do not bear on the eligibility for fees under
section 1132(g)(1), it allowed such inquiries as a second step to
determine whether a claimant found eligible should be awarded fees.
We continue to find useful the five factors delineated in our
precedent." (internal citation omitted)). The factors "that
customarily should be weighed in the balance" are the following:
(1) [T]he degree of culpability or bad faith
attributable to the losing party;
(2) the depth of the losing party's pocket,
i.e., his or her capacity to pay an award;
(3) the extent (if at all) to which such an
award would deter other persons acting under
similar circumstances;
(4) the benefit (if any) that the successful
suit confers on plan participants or
beneficiaries generally; and
(5) the relative merit of the parties'
positions.
Cottrill, 100 F.3d at 225 (citing Gray v. New Eng. Tel. & Tel.
Co., 792 F.2d 251, 257–58 (1st Cir. 1986)).
In its written opinion, the district court explained
its view that only the second factor weighed in Doe's favor. We
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find no legal or clear factual error in that exercise of the
district court's discretion. Doe argues that Harvard Pilgrim
failed to adhere to its previous "clear agreement" as to the scope
of the administrative record, making it more culpable than the
district court appreciated under the first factor, and that without
a fee award Harvard Pilgrim will not be held accountable for its
behavior. Doe I, 904 F.3d at 7. But Doe I concerned a fact-
specific procedural issue that is unlikely to arise often, and
Harvard Pilgrim's position on that issue, although ultimately
unsuccessful, was reasonable enough to convince the district
court. See id. at 6–9. Doe also complains that the district court
considered her subsequent loss in deciding whether to award fees
for her interim gain. But because the degree of success on the
merits may be considered in deciding whether an award of fees is
potentially available in the first place, Hardt, 560 U.S. at 245,
we see no reason why the district court in its discretion cannot
consider whether and to what extent an interim procedural victory
actually produced any benefits. See Gross, 763 F.3d at 83
(explaining that the Cotrill factors are not exclusive).
III.
This case is not an easy one. Ascertaining coverage
levels for mental illness can be challenging. Doe was represented
by skilled and knowledgeable counsel who helped her put her
strongest case forward. That case, though, failed to sway either
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the independent OPP reviewer or the district judge who conducted
yet another independent and de novo review. Establishing clear
error on appeal on such a record poses a difficult challenge for
the same reasons that the coverage decision itself was difficult.
Finding that Doe has not overcome that challenge, we affirm the
district court's grant of summary judgment to the defendants and
its denial of fees and costs to Doe.
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