Kissel v. United Health Care Insurance Company

Background

This document is a joint letter from the parties’ lawyers concerning the initial pretrial conference. The court approved the parties’ request not to hold that conference at the scheduled time and instead to order the proposed scheduling order.

The case concerns benefits provided to Ilan Kissel as a dependent under the Scott O. Kissel P.C. Health Plan. The letter states that the plan is fully insured by United Healthcare Insurance Company. The letter also states that the plan was named as a defendant because the parties understood that an employee benefit plan is a necessary party, but that the plan was a nominal party expected either to default or to be dismissed by agreement.

Parties’ positions

Kissel stated that he received treatment in a transitional program involving individual therapy, supervision, and other services intended to help him live independently in the community. According to Kissel, United initially denied coverage by treating the care as inpatient treatment that was not medically necessary. After Kissel showed United that the care was transitional rather than inpatient, United determined that the care was medically necessary but paid approximately $25,000 of a bill exceeding $57,000. Kissel contended that no negotiated rate existed with the treatment facility and that United improperly calculated payment based mainly on individual therapy sessions while not paying for related supervision and other services.

United stated that the plan gave it discretionary authority to decide eligibility and benefit claims. United argued that its payment decision was supported by the plan and the administrative record and should not be overturned. It also argued that Kissel’s claim for interest under New York’s Prompt Pay Law was overridden by ERISA, the federal law governing employee benefit plans, and that the Prompt Pay Law did not require payment within its specified time periods because the claims were disputed.

The parties anticipated filing motions for summary judgment after a short period of discovery. United planned to object to discovery beyond the administrative record. The parties also stated that they were discussing settlement directly and believed those discussions could be productive.

Court’s action

Judge Valerie Caproni adjourned the initial conference scheduled for October 16, 2020, to January 15, 2021, at 10:00 a.m. The court ordered the proposed scheduling order. This document does not grant or deny a motion for summary judgment and does not resolve the parties’ benefit or state-law claims.