T.G. v. United Healthcare Services, Inc.

Background

T.G. participated in an employer-sponsored health-insurance plan administered by United Healthcare Services, Inc. and United Behavioral Health, which the opinion collectively calls “United.” T.G.’s 20-year-old son, J.G., is on the autism spectrum and had depression and anxiety. In May 2018, J.G. began residential mental-health treatment at Pacific Quest in Hawaii and remained there until August 2018. T.G. and his wife paid nearly $50,000 out of pocket.

United denied coverage for the treatment. T.G. completed United’s internal appeal process and obtained an external review, which also upheld the denial. He then filed a single claim under the Employee Retirement Income Security Act (ERISA), asking for benefits under 29 U.S.C. § 1132(a)(1)(B).

The parties’ arguments

The parties filed cross-motions for summary judgment, asking the court to decide the case based on the administrative record without a trial. T.G. argued that the court should independently review United’s benefits decision under Minnesota law. He also argued that United’s focus on J.G.’s lack of suicidal thoughts conflicted with the plan’s residential-treatment guidelines, which identified the absence of imminent or current risk of harm as a requirement for residential treatment rather than a reason to deny it.

United argued that the plan gave it discretionary authority to determine eligibility for benefits and that its decision was reasonable under the evidence. United relied on the plan’s level-of-care guidelines, clinical reviews, treatment records, and the independent external review.

Court’s analysis

The court held that the plan’s grant of discretionary authority required review under the abuse-of-discretion standard. Under that standard, the decision had to be upheld if it was reasonable and supported by substantial evidence. The court rejected T.G.’s reliance on Minnesota Statutes § 62Q.107, concluding that the statute did not establish the federal standard of review and, to the extent it attempted to do so for this self-funded ERISA plan, ERISA preempted it.

The court acknowledged that United’s reviewers often emphasized J.G.’s lack of suicidal intent even though the plan treated the absence of imminent or current danger as a prerequisite for residential treatment. But the court found that United relied on additional reasons, including its conclusions that J.G. did not have a significant acute impairment, did not require 24-hour care, and could receive treatment in a less intensive setting.

The record included evidence that supported United’s position. A neuropsychologist had described J.G. as engaged, polite, punctual, and making a good effort during evaluations before treatment. The court also noted that J.G. received therapy on fewer than half of the days during his 90-day stay and often received only one hour of therapy per day. United was not required to automatically accept the treating psychologist’s opinion that residential treatment was necessary. The independent external reviewer also concluded that residential treatment was not medically necessary and that the treatment could have been provided in an outpatient setting.

Disposition

The court concluded that United’s decision was reasonable in light of the entire record, despite its “sloppy and confusing” explanations. It denied Plaintiff’s Motion for Summary Judgment and granted Defendants’ Motion for Summary Judgment. The court ordered that judgment be entered accordingly.