Fisher v. Aetna Life Insurance Company

Background

Fisher received health insurance through her husband’s law firm under a group health plan administered by Aetna. The policy used a deductible, copayments, and an annual out-of-pocket limit. Fisher purchased the brand-name antidepressant Effexor during 2015 and disputed Aetna’s treatment of the prescription costs.

The court had previously found Aetna’s denial of benefits arbitrary and capricious and remanded the matter to Aetna for further consideration. On remand, Aetna maintained that Fisher had to meet the family-plan out-of-pocket limit rather than the lower individual limit. Aetna also concluded that certain additional brand-name drug charges did not count toward the out-of-pocket limit, but it reversed one decision and paid Fisher $64.32 for the copay differential.

The court later entered summary judgment against Fisher on her claims concerning the out-of-pocket limit and the $64.32 payment. Fisher then moved for reconsideration and sought attorney’s fees and costs under the Employee Retirement Income Security Act, or ERISA.

Motion for Reconsideration

The court denied reconsideration. Fisher argued that the court had failed to apply section 18022(c) of the Affordable Care Act, which limits consumer cost-sharing, and that a 2015 rule from the U.S. Department of Health and Human Services required an embedded individual out-of-pocket limit for people covered by family plans.

The court held that the 2015 rule was a legislative rule because it imposed new obligations that were not contained in the Affordable Care Act’s text. Because the rule was legislative and was designed to apply prospectively, the court held that it could not be applied retroactively to Fisher’s 2015 coverage. The court reaffirmed that the policy’s plain language required Fisher to meet the $12,000 family out-of-pocket limit rather than the $6,000 individual limit.

The court also rejected Fisher’s request for a judgment concerning the $64.32 copay differential. It held that Aetna’s payment was a formal decision under the policy, not an unaccepted settlement offer, and therefore found no basis for entering judgment in Fisher’s favor on that amount.

Attorney’s Fees and Costs

The court held that Fisher had achieved enough success to qualify for consideration of fees because the earlier remand required Aetna to reassess its benefits decision. The court found that Aetna had acted culpably, that Aetna could pay an award, and that awarding fees would provide some deterrence. The court also found that Fisher’s success was limited: she did not obtain most of the benefits she sought, and the $64.32 payment represented only a small part of her requested relief. The court found no common benefit to a group of plan participants.

The court therefore awarded only part of the requested fees and costs. It found the attorneys’ hourly rates reasonable but excluded 20 hours billed by William Dunnegan and 9.5 hours billed by Richard Weiss for responding to an order to show cause. It then reduced the remaining fees by 75% because of Fisher’s limited success and by an additional 10% because some billing entries were vague or block-billed. From Fisher’s requested $111,326.70 in fees, the court calculated recoverable fees of $15,028.38 and added $400 in costs.

Disposition

The court denied Fisher’s motion for reconsideration in its entirety. It granted in part Fisher’s motion for attorney’s fees and costs and awarded her $15,028.38 in attorney’s fees and $400 in costs, for a total award of $15,428.38. The clerk was directed to terminate the two pending motions.