Rebecca Hamsher v. North Cypress Medical Center
Filing
29
OPINION on Summary Judgment terminating 22 . (Signed by Judge Lynn N. Hughes) Parties notified. (ghassan, 4)
UNITED STATES DISTRICT COURT
Rebecca Hamsher,
Plaintiff,
'Versus
North Cypress Medical Center
Operating Company, Ltd.,
Employee Medical Benefit Plan,
Defendant.
SOUTHERN DISTRICT OF TEXAS
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Civil Action H-I3-I4oI
Opinion on Summary Judgment
Introduction.
I.
A worker's claim under her employee-benefit plan was denied because she did not
request the sponsor to authorize the expense in advance. Rather than ask the sponsor, she
sought a certification of medical necessity from the plan's third-party claims processor. Because
the worker did not comply with the terms of the plan, she will not recover benefits.
Background.
2.
In 20II, Rebecca Hamsher- a nurse at North Cypress Medical Center- suffered from
bulimia nervosa, depression, post-traumatic stress disorder, suicidal ideation, binge eating, and
other destructive behavior.
She was treated for these at Timberline Knolls Residential Treatment Center. From
May I9 untilJune I 2, she received in-patient treatment - meaning, around-the-clock care. From
June
12
until December 27, she says that she was "partially hospitalized" for eight hours of
daily treatment.
In early June, Hamsher's mother first asked Timberline if her daughter's employeebenefit plan would cover the treatment. It told her that it had gotten "pre-certification" from a
third-party claims processor for the plan, Meritain Health. From June through December,
Hamsher and her mom repeatedly spoke with Meritain about the plan paying for her treatment.
The plan is the North Cypress Medical Center Operating Company, Ltd., Employee
Medical Benefits Plan. In early 2012, the plan administrator denied her claim because she had
not asked the human resources department at North Cypress to authorize the expense in
advance - an exclusion under the plan for care received at hospitals other than North Cypress.
Hamsher appealed the administrator's decision to this court.
3.
Plan.
Under the plan, treatment is required at North Cypress unless (a) the treatment is not
available at North Cypress and (b) the patient obtains "prior authorization" from the human
resources department at North Cypress.
4-
Authorization.
The plan decision to deny Hamsher's claim was far from arbitrary.' It concluded that,
before getting treated, she had not obtained authorization for her treatment from the human
resources department at North Cypress. Assuming every fact that she has pleaded is true, she
concedes that she did not ask human resources to approve her treatment.
5.
Certification.
In her brief, Hamsher exhaustively explains her correspondence with Meritain Health
about "pre-certification." She confuses (a) certification of medical necessity from a third-party
claims processor with (b) authorization from the plan sponsor, North Cypress itself.
North Cypress is a hospital. It and the plan save money when participants are treated
by North Cypress. For this reason, it had excluded treatment from other hospitals unless it
agrees treatment elsewhere is necessary. This cost-saving requirement has nothing to do with
a certification of medical necessity. It is not arbitrary or otherwise pernicious. It allows the
employer to devise a plan, wages, and other labor costs into a package that it concludes best
suits the hospital and its workers.
I
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, II4-15 (1989).
The vast majority of what Hamsher said to Meritain was also not in the record that the
plan reviewed when it denied her claim. In reviewing that denial, this court is limited to the
evidence before the plan administrator. 2 Hamsher persists in going outside of this record. Her
insulting Meritain may be justified, but its incompetence is not in the record and does not
change her choice to avoid the plan's requirements.
6.
Disco'Very.
Hamsher wants discovery about North Cypress's relationship with Meritain and
Meritain's correspondence with Timberline Knolls. Given the plan's unequivocal requirement
that she seek authorization from human resources at North Cypress, this data is irrelevant.
Irrespective of what happened with Meritain, she cannot prevail.
Assuming the data she has requested is relevant, her motion for discovery would still
be denied. This court will not consider facts that were not in the record that the plan
administrator reviewed. The misguided tact of this case, seeking every extraneous path, is
exactly why - 40 years ago - Congress adopted a law that restricts litigation in ERISA cases to
appeals from the administrative record. Every motion and deposition that she would take
consumes resources that are dedicated to her fellow workers' benefits. It is them, not the
hospital or claims agent, whom she is beggaring.
7.
Equiry.
A worker may sue to recover for benefits owed to her under the plan or for equitable
relief if she has no other remedy. 3 She may not, however, bring both claims simultaneously
because her claim for benefits is a tacit admission that she has another remedy.4
2
Vega v. National Life Ins., Inc., 188 F.3d 287,299 (5th Cir. 1999).
3
Sec 29 U.s.c. § (a)(I)(B) (benefits); 29 U.s.c. § II32 (a)(3) (equity).
4 Rhorer v. Raytheon Engineers &- Constructors. Inc., 181 F.3d 634,639 (5th Cir.
1999)·
8.
Conclusion.
Hamsher was not confused by the two permissions - certification and authorization.
She indicated through counsel that she did not want to be treated by her co,workers. \Vhile
that is understandable, it does not relieve her from complying with the plan. Had she asked, she
may have been given permission to go elsewhere. She chose not to allow the plan to decide.
Rebecca Hamsher will take nothing from the North Cypress Medical Center Operating
Company, Ltd., Employee Medical Benefit Plan because she did not comply with the
unequivocal requirement that she ask the plan sponsor to authoriz;e her treatment.
Signed on August
L, 2014, at Houston, Texas.
Lynn N. Hughes
United States DistrictJudge
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