Jamie F. v. UnitedHealthcare Insurance Company

Background

Jamie F. brought a claim under the Employee Retirement Income Security Act (ERISA), a federal law governing many employee-benefit plans. She sought benefits under a plan covering her as a dependent through her mother’s group employee-benefit plan. UnitedHealthcare Insurance Company underwrote the medical-benefit policy and administered mental-health claims through United Behavioral Health, doing business as Optum.

After Jamie F. was hospitalized at Stanford in February 2018 for problems including severe food restriction, weight loss, bradycardia, and self-harming behavior, her treating physicians recommended immediate transfer to Avalon Hills, a residential treatment facility in Utah. UnitedHealthcare denied authorization for the treatment, determining that residential care was not medically necessary and that Jamie F. could receive care through a partial-hospitalization program closer to home. Jamie F. received treatment at Avalon Hills from February 22 through July 16, 2018.

The plan covered mental-health services, including residential treatment, only when they were medically necessary. The plan defined medical necessity to require, among other things, that the service comply with generally accepted medical practice, be clinically appropriate and effective, and not be more costly than an alternative service likely to produce equivalent results. The parties agreed that the court would review the benefits claim de novo, meaning the court would independently decide whether Jamie F. established her entitlement to benefits rather than defer to UnitedHealthcare’s decision.

The Court’s Findings

The parties filed cross-motions for summary judgment, but they agreed at the hearing that the motions were actually requests for judgment under Federal Rule of Civil Procedure 52. The court therefore treated the order as containing findings of fact and conclusions of law based on the administrative record.

The court found, by a preponderance of the evidence, that Jamie F. was entitled to coverage for the Avalon Hills residential treatment. The court relied on her diagnosis of severe anorexia nervosa, co-occurring anxiety, depression, and obsessive-compulsive disorder, her treatment history, her medically fragile condition, and the recommendations of her treating physicians. Those physicians explained that Jamie F. needed a highly structured residential setting because of her difficulty maintaining nutrition, rapid relapses, medical instability, and the inability of outpatient care and family support to provide equally safe and effective treatment.

The court concluded that UnitedHealthcare’s reviewers did not conduct an adequately thorough evaluation of the medical evidence. The initial review focused on Jamie F.’s weight, lack of current suicidal behavior, and family support, while the later review repeated that reasoning. The court found that the reviewers did not adequately address the treating doctors’ opinions, the severity of Jamie F.’s symptoms, her co-occurring conditions, or why partial hospitalization would be safe and just as effective as residential treatment.

The court also questioned whether UnitedHealthcare’s Optum level-of-care guidelines represented generally accepted medical practice in this context. It noted that other courts had found problems with those guidelines and that they did not specifically address eating disorders or factors such as healthy body weight, cardiac function, nutrition, compulsive exercise, and the structure needed to maintain medical stability. In any event, the court found that the guidelines did not support UnitedHealthcare’s decision because the reviewers failed to explain why a lower level of care would safely and effectively address Jamie F.’s condition and history.

Disposition

The court GRANTED Jamie F.’s motion for judgment and DENIED UnitedHealthcare’s cross-motion. It found that Jamie F. was entitled to coverage for the residential treatment provided by Avalon Hills in 2018. The parties were ordered, within 30 days of the order, to meet and confer to resolve the amount of unpaid benefits and submit a proposed judgment approved as to form.

The court also GRANTED the administrative motions to seal the administrative record and the motion to seal a one-page errata to that record. The order states that the rulings on the two main motions terminated Docket Nos. 29 and 34.