S. et al v. Boeing Company Employee Health Benefit Plan, The et al

Filing 52

MEMORANDUM DECISION AND ORDER granting 29 Defendants' Motion for Summary Judgment and denying 30 Plaintiff's Motion for Summary Judgment: The court concludes that Plaintiff's action was timely filed. However, ValueO ptions' denial of benefits was reasonable. Thus, Plaintiff's Motion for Summary Judgment is DENIED, and ValueOptions' Motion for Summary Judgment is GRANTED. The Clerk of Court is directed to close the case. Signed by Judge Robert J. Shelby on 9/25/18. (dla)

IN THE UNITED STATES DISTRICT COURT
DISTRICT OF UTAH, NORTHERN DIVISION
STACY S., individually and as guardian of
M.K., a minor,
Plaintiff,
v.
THE BOEING COMPANY EMPLOYEE
HEALTH BENEFIT PLAN (PLAN 626), and
VALUEOPTIONS,
Defendants.

MEMORANDUM DECISION AND
ORDER GRANTING DEFENDANTS’
MOTION FOR SUMMARY JUDGMENT
AND DENYING PLAINTIFF’S MOTION
FOR SUMMARY JUDGMENT

Case No.: 1:15-CV-72
District Judge Robert J. Shelby

This case involves medical treatment that M.K., a minor, received from March 27 to July
1, 2013. Plaintiff, M.K.’s mother, brought this action for recovery of medical benefits that
Defendants Boeing Company Employee Health Benefit Plan and ValueOptions (collectively,
ValueOptions) denied. Plaintiff and ValueOptions each filed a Motion for Summary Judgment.
For the reasons stated below, Plaintiff’s Motion for Summary Judgment is DENIED 1 and
ValueOptions’ Motion for Summary Judgment is GRANTED. 2
BACKGROUND
M.K. is a beneficiary of the Boeing Company Employee Health Benefit Plan (the Plan).
Drawing on the criteria explained in the Plan, ValueOptions denied Plaintiff’s request for
coverage for M.K.’s stay at Aspen, a residential treatment center (RTC) in Utah.
The Plan Language
The Plan provides benefits for Boeing employees, spouses, and dependents. The
summary plan description (SPD) states that the Boeing Company Board of Directors designated

1

Dkt. 30.

2

Dkt. 29.

a committee to serve as Plan Administrator, which has the “absolute discretion” to “[d]elegate its
administrative duties and responsibilities to persons or entities of its choice such as the Boeing
Service Center, the service representatives, and employees of the Company.” 3 The SPD also
states that “[a]ll decisions that the Plan Administrator (or any duly authorized designees) makes
with respect to any matter arising under the Plan and any other Plan documents are final and
binding.” 4 The SPD defines “service representative” as “an agent that the Company has
contracted with to make benefit determinations and administer benefit payments under the plans
described in this booklet.” 5 ValueOptions is listed as the service representative for mental health
benefits. 6 Under the heading “Who Administers the Benefits,” the SPD states, “the Company
has contracted various service representatives to handle the day-to-day administration of the
plan. Service representatives answer benefit questions, make benefit decisions, pay claims,
process claim appeals, and account for premiums, service fees and claim costs.” 7
The SPD also states a beneficiary may file a civil action in the district court within 180
days after “[d]ecision on appeal of your claim for benefits or eligibility.” 8
Denial of Coverage
This case stems from a denial of coverage for M.K.’s stay at Aspen, an RTC. Prior to her
stay at Aspen, M.K. had been hospitalized at Seattle Children’s Hospital after Plaintiff
discovered M.K. was cutting herself. M.K.’s physician at Seattle Children’s Hospital modified
M.K.’s medication, and M.K. was discharged on March 9, 2013, with her physician’s

3

R. 44.

4

Id.

5

R. 1215.

6

R. 1217.

7

R. 1147.

8

R. 1192.

2

recommendation that she participate in outpatient therapy. 9 The physician noted that M.K.
“reported fewer thoughts to harm herself, and these stopped before discharge.” 10
M.K. was admitted to Aspen on March 27, 2013. An Aspen representative contacted
ValueOptions to request authorization for M.K.’s inpatient mental health services.
ValueOptions’ medical director reviewed Aspen’s request and concluded M.K. did not meet the
criteria for acute in-patient hospitalization because she had shown improvement concerning her
psychotic symptoms. 11 Instead, the medical director informed Plaintiff that an appropriate level
of care would be partial hospitalization with intensive/structured setting.
ValueOptions notified Plaintiff of her right to appeal this decision in a letter sent March
29, 2013. 12 The letter stated that the proposed admission “was for evaluation and treatment of
behaviors and symptoms of psychosis such as disorganized thoughts, hearing voices, or
aggressive behaviors, indicating a risk of harm to self or others.” 13 Based on the information
provided as of March 27, 2013, ValueOptions stated its review did not “indicate the presence of
behavior or thinking which would meet criteria for Acute Inpatient Hospitalization with 24 hour
Medical Supervision.” 14 Rather, ValueOptions stated that “[a]n appropriate level of care to the
current needs of the patient is Partial Hospitalization with Intensive/Structured setting.” 15

9

R. 882.

10

R. 883.

11

R. 975.

12

R. 1021.

13

Id.

14

Id.

15

Id.

3

Aspen notified ValueOptions that if M.K. stepped down to a lower level of care such as
RTC services, Aspen would contact ValueOptions for precertification. 16 Although Aspen
provided M.K. with RTC services, it did not contact ValueOptions for precertification.
On May 13, ValueOptions received a claim from Aspen for RTC services provided from
March 27 to April 30, 2013. ValueOptions denied the claim on the basis that the services had
not been authorized. 17 After receiving more information from Plaintiff, ValueOptions’ medical
director reviewed the claim again in October 2013 and determined the services could not be
certified because the criteria for RTC services had not been met. 18 The medical director noted
that many of the symptoms reported occurred before M.K.’s hospitalization and that M.K.’s
outpatient therapist had expressed a concern that Plaintiff was seeking long-term placement for
M.K. because she did not want her to return home.
ValueOptions’ letter to Plaintiff notifying her of this decision recited the same clinical
rationale as the March 27 letter, except it replaced “Acute Inpatient Hospitalization with 24 hour
Medical Supervision” with “Residential Treatment Setting.” 19
Plaintiff requested an appeal of the denial in April 2014. Plaintiff included a letter from
M.K.’s outpatient therapist, who stated that long-term residential treatment “seems to be
consistent with [his] impressions gathered over time, of [M.K.]’s growing needs.” 20 A
psychiatrist who was not involved in prior decisions reviewed M.K.’s records and advised that
RTC services should not be certified because M.K. did not exhibit any behavior or thinking that

16

R. 973.

17

R. 979.

18

R. 981.

19

R. 91.

20

R. 880.

4

would warrant RTC services and that she could have been treated safely in a home setting
through adolescent partial hospitalization or intensive outpatient treatment. 21
ValueOptions notified Plaintiff of this decision on May 1, 2014. 22 The denial stated that
ValueOptions’ review “included any additional information received in support of your appeal.”
The denial was based on the psychiatrist’s determination that M.K. “could have safely been
treated in Adolescent Partial Hospitalization or Intensive Outpatient Treatment and remained in
the home setting” and that she did not “show any behavior or thinking which would need the
requested level of [residential treatment] care.” The denial notified Plaintiff that the review was
“the final level of appeal available to you through ValueOptions and your plan,” but it did not
notify Plaintiff of her 180-day time limit to file an action with the district court.
Plaintiff requested an external appeal, which Allmed was randomly selected to conduct.
Allmed reviewed Plaintiff’s appeal letters, M.K.’s medical records from Aspen, ValueOptions’
denial letter, the Plan language, and ValueOptions’ clinical criteria for child/adolescent RTC
services. Allmed notified Plaintiff on October 16, 2014 that the RTC services were “not
clinically appropriate, known to be effective for or consistent with the patient’s condition, or in
accordance with the generally accepted standards for residential care based on current
literature.” 23 Allmed stated M.K. “was not actively suicidal during her stay at [Aspen]” and that
the self-injurious behavior she did exhibit “was superficial at best and did not require 24-hour
intense supervision to control.” 24 The letter also stated M.K. “did not manifest overt repetitive
outbursts of aggression that required containment in a facility,” and that her treatment “could

21

R. 986.

22

R. 1030.

23

R. 1036.

24

R. 1037.

5

have taken place safely and effectively at a lower level of care.” The letter addressed M.K.’s
weight as a health concern, but noted she did not have repetitive hospitalizations, did not fail at
attempts at lower levels of care, and “did not demonstrate a home or community environment
that would be considered not conducive to conducting treatment.”
Following the denials, Plaintiff filed her Complaint on June 5, 2015, seeking $79,350 for
denied medical benefits. 25
LEGAL STANDARD
Where, as here, the parties in an ERISA case both move for summary judgment, “the
factual determination of eligibility for benefits is decided solely on the administrative record, and
the non-moving party is not entitled to the usual inferences in its favor.” 26 Additionally, the
court considers “only the arguments and evidence before the administrator at the time it made
[the] decision.” 27
ANALYSIS
ValueOptions argues Plaintiff’s civil action was untimely filed and should be dismissed.
In the alternative, ValueOptions contends its decision to deny M.K. benefits was reasonable.
Plaintiff argues the untimeliness of her action should be excused. She maintains the court should
review the denial of benefits de novo, and hold that ValueOptions should have covered the RTC
services.

25

Dkt. 2.

26

LaAsmar v. Phelps Dodge Corp. Life, Accidental Death & Dismemberment & Dependent Life Ins. Plan, 605 F.3d

789, 796 (10th Cir. 2010).
27

Sandoval v. Aetna Life & Cas. Ins. Co., 967 F.2d 377, 380 (10th Cir. 1992).

6

I.

Timeliness
ValueOptions first argues Plaintiff’s claim must be dismissed as untimely because she did

not file suit within 180 days of ValueOptions’ final denial, as required by the Plan.
ERISA does not contain a limitations provision for district court actions, but parties may
contractually agree on a time limit.28 The Plan in this case requires filing a civil action within
180 days after notification of a final denial of benefits. Plaintiff does not dispute that she missed
the 180-day deadline, but she argues the time limit is unenforceable because ValueOptions’
failure to include the time limit in adverse benefit determination letters violated ERISA’s claims
procedure regulations. 29 The parties disagree about whether such a notification was required.
A. ERISA’s requirements
Two sections of ERISA address the information a plan administrator is required to
include in its adverse benefit determinations. The court includes below the entirety of both,
observing that the first includes in Subsection (iv) reference to “the time limits applicable” to
review procedures. This provision is noticeably absent in Subsection 4 of the second applicable
ERISA section. The first relevant section, 29 C.F.R. § 2560.503-1(g), is titled “Manner and
content of notification of benefit determination.” This section mandates that “any adverse
benefit determination” include:
(i)
The specific reason or reasons for the adverse determination;
(ii)
Reference to the specific plan provisions on which the determination is
based;

28

Salisbury v. Hartford Life & Acc. Co., 583 F.3d 1245, 1247 (10th Cir. 2009).

29

Plaintiff also argues ValueOptions cannot enforce the contractual statute of limitations because (1) it failed to

raise the time limit as an affirmative defense in its Answer, and (2) the sole reference to the 180-day deadline in the
SPD was unclear, in violation of ERISA’s requirement that the SPD “reasonably apprise such participants and
beneficiaries of their rights and obligations under the plan.” 29 U.S.C. § 1022. Because the court concludes
ValueOptions was required to notify Plaintiff of the deadline in its denial letters, it need not reach these issues.

7

(iii) A description of any additional material or information necessary for the
claimant to perfect the claim and an explanation of why such material or
information is necessary;
(iv)
A description of the plan’s review procedures and the time limits applicable
to such procedures, including a statement of the claimant’s right to bring a civil
action under section 502(a) of the Act following an adverse benefit determination
on review.
The second relevant portion of ERISA, Section 2560.503-1(j), addresses “Manner and
content of notification of benefit determination on review.” This section requires an adverse
benefit determination on review to include:
1)
The specific reason or reasons for the adverse determination;
2)
Reference to the specific plan provisions on which the benefit determination
is based;
3)
A statement that the claimant is entitled to receive, upon request and free of
charge, reasonable access to, and copies of, all documents, records, and other
information relevant to the claimant’s claim for benefits. . . .
4)
A statement describing any voluntary appeal procedures offered by the plan
and the claimant’s right to obtain the information about such procedures . . . and a
statement of the claimant’s right to bring an action under section 502(a) of the Act.
The court must take into account both sections when determining whether an adverse
benefit determination on review must include the applicable time limits for the claimant’s right
to bring an action under Section 502(a), which is the claimant’s avenue to file a civil action in
district court.
B. Split in authority
The majority of courts that have interpreted Section (g)(1)(iv) conclude it requires a plan
administrator to include, in adverse benefit determinations, the time limits for a civil action. 30
These courts find the plain language of Section (g)(1)(iv) compels that result because the
position of the word “including” means the claimant’s right to bring a civil action is part of the

30

See, e.g., Santana-Diaz v. Metro. Life Ins. Co., 816 F.3d 172, 180 (1st Cir. 2016); Mirza v. Ins. Adm’r of Am., Inc.,

800 F.3d 129, 136 (3d Cir. 2015); Moyer v. Metro. Life Ins. Co., 762 F.3d 503, 505 (6th Cir. 2014).

8

plan’s review procedures. A contrary interpretation, in which notification of time limits for
“review procedures” and notification of the right to bring a civil action are two distinct
requirements, would read out the word “including” and replace it with “and.” 31 The First, Third,
and Sixth Circuits have held that such an interpretation does violence to plain text. 32 Thus, these
courts conclude adverse benefit determinations must disclose the time limit for a claimant to file
a civil action. However, none of these courts addressed how Section (g) interacts with Section
(j)(4), which deals directly with adverse benefit determinations on review but omits Section
(g)(1)(iv)’s language concerning time limits. 33
The Tenth Circuit has not directly addressed this question. The Court addressed a related
issue in Hancock v. Metropolitan Life Insurance, in which a claimant argued the plan
administrator violated Sections (g)(1)(ii) and (g)(1)(iii) by providing her with a denial of an
appeal that did not cite the provision upon which the denial was based and did not explain how
she could perfect her claim. 34 The Tenth Circuit rejected that argument, stating that Section (g)
“applies only to denials of benefits, not denials of appeals.” 35 Although the Court referred to
Section (g) as a whole, it applied only Section (g)(1)(ii) and (g)(1)(iii). In other words, the Court
did not address Section (g)(1)(iv), and its holding does not contradict the conclusion in other
Circuits that Section (g)(1)(iv)’s time limits notice requirement applies to final denials.
Given the nature of a final denial, there was no reason for the Tenth Circuit to apply
either Section (g)(1)(ii) or Section (g)(1)(iii) in the context of denial of an appeal. To begin with,

31

See Santana-Diaz, 816 F.3d at 180.

32

See id. at 180; Mirza, 800 F.3d at 136; Moyer, 762 F.3d at 505.

33

See Santana-Diaz, 816 F.3d at 181 n.8 (noting the possibility that Section (g)(1)(iv) applies only to initial, rather

than final, benefit determinations, but concluding it was unnecessary to reach the question).
34

590 F.3d 1141, 1152 (10th Cir. 2009).

35

Id. at 1153.

9

Section (g)(1)(ii)’s requirement of a “[r]eference to the specific plan provisions on which the
determination is based” is repeated nearly verbatim in Section (j)(2), making application of
Section (g)(1)(ii) unnecessary for final denials. Additionally, Section (g)(1)(iii)’s requirement of
a “description of any additional material or information necessary for the claimant to perfect the
claim” is nonsensical in the context of a final benefit determination, because the claimant has
already exhausted her opportunities to provide such additional information. Thus, Hancock’s
determination that Sections (g)(1)(ii) and (g)(1)(iii) do not apply to final benefit determinations
has no bearing on Section (g)(1)(iv)’s potential relevance.
The Tenth Circuit also addressed a similar issue in an unpublished decision, Young v.
United Parcel Services. 36 In that case, the Court interpreted language in an SPD stating an
adverse benefit determination would contain “a description of the Plan’s appeal procedures and
the time limits applicable to such procedures, including a statement of your right to bring a civil
action following a denial of your appeal.” 37 The claimant argued that language required the plan
administrator to notify her of the time limit for filing a civil action. The Court rejected that
argument, stating that the “internal appeals process” was separate from “the filing of a legal
action after that process has been fully exhausted,” and that the SPD required time limits only for
the former. 38
Like Hancock, Young did not address the application of Section (g)(1)(iv). Additionally,
two decisions in District of Utah cases have recently noted that Section (g)’s language is broader

36

416 F. App’x 734 (10th Cir. 2011).

37

Id. at 739.

38

Id. at 740.

10

than the SPD in Young. 39 Both decisions observe that Section (g) requires notification of time
limits for “the plan’s review procedures,” which includes both internal appeals and judicial
review. 40 Thus, Young’s holding is unhelpful for answering the question before the court today.
Because neither Hancock nor Young addressed Section (g)(1)(iv), district courts in the
Tenth Circuit have been left with little guidance, giving rise to a split within this district.
The first District of Utah case to address this question was Michael C.D. v. United
Healthcare. 41 The court in Michael C.D. stated that Young’s holding concerning SPD language
was persuasive for interpreting Section (g)(1)(iv). 42 Applying Young, the court concluded
Section (g) applies only to initial benefit determinations, and that Section (j) addresses final
benefit determinations. Because the time to file a civil action is not triggered until the final
benefit determination, the court stated it would be “counterintuitive” to require plan
administrators to give claimants notice of that timeline in an initial determination but not a final
determination. 43 Thus, the court concluded Section (g)(1)(iv) “only requires initial denial letters
to include time limits applicable to a plan administrator’s internal review procedures,” and
Section (j) “does not require the plan administrator to include any time limits for review
procedures in the final denial letters.” 44

39

William G. v. United Healthcare, No. 1:16-CV-00144-DN, 2017 WL 2414607, at *7 (D. Utah June 2, 2017); John

H. v. United Healthcare, No. 1:16-cv-110-TC, 2017 U.S. Dist. LEXIS 73593 (D. Utah April 26, 2017).
40

Id.

41

No. 2:15-CV-306-DAK, 2016 U.S. Dist. LEXIS 64867 (D. Utah May 17, 2016).

42

Id. at *13.

43

Id. at *14.

44

Id.

11

The same issue was presented a year later in John H. v. United Healthcare. 45 The court
there stated “[t]he word ‘including’ necessarily modifies its previous clause, ‘a description of the
plan’s review procedures,’” leading to the conclusion that a civil action is one of the “review
procedures” for which a plan administrator must disclose the time limit.46 The court explained
this interpretation “aligns with ERISA’s remedial nature” because “[c]laimants are more likely to
read a relatively short denial letter, as opposed to long, complex plan documents.” 47 In light of
the text and policy considerations, the court found Young unpersuasive. 48 Section (j)(4)’s lack of
an explicit requirement for notification of time limits did not alter the court’s conclusion.
Rather, the court noted that Section (g) applies to “any adverse benefit determination,” which
means “final denial letters must meet the requirements of both Subsection (g)(1)(iv) and the
requirements of Subsection (j)(4).” 49
This question arose again in William G. v. United Healthcare. 50 In that case, the court
concluded that the only proper reading of Section (g)(1)(iv)’s use of the word “including” is that
the section requires notification of time limits for civil actions in all denial letters. 51 The court
pointed to the differences between Section (g) and Section (j), noting that Section (g) refers to
“review procedures” as opposed to Section (j)’s “appeal procedures.” 52 This, the court stated,
was further evidence that the two sections do not conflict: “If the Department of Labor intended

45

No. 1:16-cv-110-TC, 2017 U.S. Dist. LEXIS 73593 (D. Utah April 26, 2017).

46

Id. at * 6.

47

Id. at *7 (internal quotation marks omitted).

48

Id. *13.

49

Id. *14.

50

No. 1:16-CV-00144-DN, 2017 WL 2414607 (D. Utah June 2, 2017).

51

Id. at *5.

52

Id.

12

that Subsection (g)(1)(iv) require denial letters to disclose only time limits related to internal
appeal procedures, it would have used the more narrow phase —‘appeal procedures’—found in
Subsection (j)(4)(i) rather than the broader phrase—‘review procedures’—when drafting
Subsection (g)(1)(iv).” 53 And the court rejected the reasoning of Michael C.D., stating that such
a reading would render the word “any” in Subsection (g) superfluous. 54 The court concluded
final benefit determinations must satisfy both Subsection (g) and Subsection (j)’s requirements.
This court is now presented with the same issue. For largely the same reasons articulated
in the decision, the court agrees with the holdings in John H. and William G., and concludes final
benefit determinations must notify the claimant of the time limit to file an action in district court.
This is explained more fully in the next Section.
C. Application of canons of statutory construction
When analyzing a regulation, the court applies ordinary principles of statutory
construction. 55 “Statutory construction must begin with the language employed by Congress and
the assumption that the ordinary meaning of that language accurately expresses the legislative
purpose.” 56 Courts also must interpret statutes so that “if it can be prevented, no clause,
sentence, or word shall be superfluous, void, or insignificant.” 57 Another canon of statutory
construction provides that “a negative inference may be drawn from the exclusion of language
from one statutory provision that is included in other provisions of the same statute.” 58

53

Id.

54

Id. at *6.

55

Time Warner Entm’t Co., L.P. v. Everest Midwest Licensee, L.L.C., 381 F.3d 1039, 1050 (10th Cir. 2004).

56

Park ‘N Fly, Inc. v. Dollar Park & Fly, Inc., 469 U.S. 189, 194 (1985).

57

TRW Inc. v. Andrews, 534 U.S. 19, 31 (2001).

58

Hamdan v. Rumsfeld, 548 U.S. 557, 578 (2006).

13

The court recognizes that no reconciliation of Sections (g) and (j) would perfectly effect
all the above-mentioned canons of statutory construction. Applying the plain language of
Section (g) leads to the conclusion that “any adverse benefit determination” includes final
determinations. But that reading renders several portions superfluous. If Sections (g)(1)(i) and
(ii) already require a final determination to contain “[t]he specific reason or reasons for the
adverse determination” and a “[r]eference to the specific plan provisions on which the
determination is based,” then there would be no need for Section (j) to repeat those requirements.
Additionally, Section (g)(1)(iv)’s requirement that the plan administrator notify a claimant of the
right to bring a civil action is repeated in Section (j)(iv) but without Section (g)’s language about
time limits, which seems to implicate the negative-inference canon. Thus, no reading of the
statute perfectly harmonizes the two sections.
Given this tension, the best solution is to rely on the plain language and conclude that any
superfluousness that occurs is the result of Congress’ intent to craft a statute that leaves no doubt
as to the importance of explaining adverse benefit determinations to claimants.
Under this reading, Section (g)’s language concerning “any adverse benefit
determination” includes final denials. The court finds no support in the plain language for the
conclusion that Section (g) applies only to initial benefit determinations. Rather, the word “any”
encompasses “final.”
Additionally, the court agrees with the conclusion in William G. that giving meaning to
the word “including” in Section (g)(1)(iv) must mean that a civil action is one of the “review
procedures” for which a time limit must be provided. “[T]he word ‘including’ cannot be easily
removed or changed since it modifies the word ‘description,’ which is followed by a
prepositional phrase explaining what must be described—the plan’s review procedures and

14

applicable time limits for those procedures.” 59 The resulting conclusion is that any benefit
determination requires notification of a time limit for filing a civil action.
This interpretation admittedly results in some duplication of requirements between
Sections (g) and (j), namely the reasons for the adverse determination, the reference to the
provision on which the determination is based, and the notification of the right to file a civil
action. But this duplication reflects ERISA’s policy considerations. ERISA “is remedial
legislation that should be construed liberally in favor of those persons it was meant to benefit,
namely participants . . . and beneficiaries.” 60 Congress’ stated intent in enacting ERISA was
to protect interstate commerce and the interests of participants in employee benefit
plans and their beneficiaries, by requiring the disclosure and reporting to
participants and beneficiaries of financial and other information with respect
thereto, by establishing standards of conduct, responsibility, and obligation for
fiduciaries of employee benefit plans, and by providing for appropriate remedies,
sanctions, and ready access to the Federal courts. 61
The duplication of Section (g)’s provisions serves to highlight several of those stated
purposes, including the importance of disclosure of information to participants and ready access
to federal courts.
Additionally, as the First Circuit Court of Appeals noted, “[c]laimants are obviously more
likely to read information stated in the final denial letter, as opposed to included (or possibly
buried) somewhere in the plan documents, particularly since, as was the case here, plan
documents could have been given to a claimant years before his claim for benefits is denied.” 62
Reading Sections (g) and (j) to require notification of the time limit for a district court action in

59

William G., 2017 WL 2414607, at *5 (internal quotation marks omitted).

60

Jenkins v. Green Bay Packaging, Inc., 39 F.3d 1192 (10th Cir. 1994) (unpublished) (citation omitted).

61

29 U.S.C. § 1001.

62

Santana-Diaz, 816 F.3d at 181.

15

final benefit determinations supports Congress’ intent to facilitate claimant’s easy access to
important information, and it avoids the “counterintuitive” approach that the court in Michael
C.D. noted. When taking into account Congress’ policy considerations, this interpretation does
not do violence to the text of the regulation.
Given the plain language of Sections (g) and (j), the court concludes a final benefit
determination must notify the claimant of the time limit for filing a civil action.
D. Remedy for noncompliance
ValueOptions does not dispute that it failed to provide notification of the Plan’s 180-day
time limit. As the court recognized in William G., “there are two potential consequences” for a
plan’s failure to notify claimants of the time limit for a civil action in final adverse benefit
determinations—equitable tolling or “presuming prejudice and rendering the Plan’s limitations
period unenforceable.” 63
ValueOptions does not argue the court should apply equitable tolling here, and, in any
case, the court concludes equitable tolling would be inappropriate. Section (g) requires
notification of the time limit in benefit determinations and does not appear to contemplate an
alternative method of notification. To allow plan administrators to avoid this requirement
through equitable tolling “would render hollow the important disclosure function of § 2560.503–
1(g)(1)(iv), as plan administrators would then have no reason at all to comply with their
obligation to include contractual time limits for judicial review in benefit denial letters.” 64

63

William G., 2017 WL 2414607, at *9.

64

Santana-Diaz, 816 F.3d at 184.

16

The better rule is that a plan administrator who fails to notify claimants of the time limit
cannot rely on that time limit to bar a late-filed civil action. 65 The court therefore will not apply
the Plan’s 180-day time limit to Plaintiff’s civil action.
Where no contractual time limit applies to an ERISA case, the court applies “the most
closely analogous statute of limitations under state law.” 66 In Utah, the most analogous statute
of limitations for an ERISA plan is the six-year time limit for a breach of contract action. 67 In
this case, ValueOptions notified Plaintiff of its final denial of her claim on May 1, 2014. 68
Plaintiff filed her civil action on June 5, 2015, well within the six-year statute of limitations. 69
As a result, Plaintiff’s action was timely filed and the court must address Plaintiff’s arguments on
the merits of the denial of benefits.
II.

Denial of benefits
Plaintiff urges the court to hold that ValueOptions should have covered M.K.’s RTC

services at Aspen, while ValueOptions argues the court should uphold the denial. To resolve this
question, the court must first determine which standard of review applies.
A. Standard of review
The court reviews a denial of benefits under a de novo standard “unless the benefit plan
gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or
to construe the terms of the plan.” 70 If the administrator or fiduciary has reserved its

65

Accord id. at 180; Mirza, 800 F.3d at 136; Moyer, 762 F.3d at 505; John H. v. United Healthcare, 2017 U.S. Dist.

LEXIS 73593 at *7–8.
66

Salisbury, 583 F.3d at 1247 (citation omitted).

67

Michael C.D., 2016 WL 2888984, at *2 (citing Utah Code § 78B-2-309(2)).

68

R. 1030.

69

Dkt. 2.

70

Hancock v. Metro. Life Ins. Co., 590 F.3d 1141, 1146 (10th Cir. 2009) (citation omitted).

17

discretionary authority, “then, absent procedural irregularities, the denial of benefits is reviewed
under an arbitrary and capricious standard.” 71
The Tenth Circuit has been “comparatively liberal in construing language to trigger the
more deferential standard of review under ERISA.” 72 Courts do not require “any magic words,
such as ‘discretion,’ ‘deference,’ ‘construe’ or ‘interpret’ in order to find discretionary
authority.” 73
For example, the Tenth Circuit has concluded that discretionary authority was granted
where the plan grants authority “to interpret the terms of the Plan and to determine eligibility for
and entitlement to Plan benefits in accordance with the terms of the Plan,” 74 and where a plan
stated the plan administrator “makes all final decisions about benefits paid from the Plan.” 75
Additionally, courts have found language providing that the plan administrator “determines”
benefits is sufficient to convey discretion. 76
Plaintiff argues a de novo review applies for two reasons: (1) the record contains only the
SPD, not the Plan, and (2) even if the SPD is sufficient, it does not grant discretionary authority
for determining benefits.
Plaintiff first argues that because the administrative record contains only the SPD and not
the Plan itself, the court cannot determine whether the Plan grants discretionary authority to
ValueOptions.

71

Kellogg v. Metro. Life Ins. Co., 549 F.3d 818, 825 (10th Cir. 2008).

72

Nance v. Sun Life Assur. Co. of Canada, 294 F.3d 1263, 1268 (10th Cir. 2002).

73

Eugene S., 2010 WL 5300897, at *2 (citations omitted).

74

Hancock, 590 F.3d at 1146.

75

Geddes v. United Staffing Alliance Emp. Med. Plan, 469 F.3d 919, 924 (10th Cir. 2006).

76

Henderson v. Hartford Life & Acc. Ins. Co., No. 2:11-CV-187-DAK, 2012 WL 2419961, at *4 (D. Utah June 26,

2012) (citing Winchester v. Prudential Life Inc. Co., 975 F.2d 1479, 1483 (10th Cir. 1992)).

18

The Tenth Circuit rejected a similar argument in Eugene S. v. Horizon Blue Cross Blue
Shield. 77 In that case, the Court noted the SPD contained the relevant language of the Plan,
making it sufficient for the court to review. 78 The Court also noted that the plaintiff did not
request a copy of the plan or ask the district court to delay ruling on the parties’ summary
judgment motions so he could obtain a copy. 79
Plaintiff in this case has not requested that a copy of the Plan be placed in the
administrative record or that the court delay its ruling. Additionally, the SPD states that it is part
of the Plan and one of several “governing documents.” Finally, Plaintiff has not argued what
parts of the Plan are relevant to her arguments but not included in the SPD. Thus, the court
concludes the language in the SPD is sufficient when analyzing whether the Plan grants
discretionary authority.
Plaintiff also argues the Plan delegates discretionary authority to ValueOptions only for
administrative duties and not for determining whether services should be covered. Plaintiff is
correct that the Plan uses explicit delegation language only for “administrative duties and
responsibilities.” 80 However, the Plan states that service representatives may “make benefit
determinations.” 81
There is no meaningful difference between the authority to “determine” benefits and the
authority to “make benefit determinations.” Both terms inherently require some exercise of
discretion. The authority to make benefit determinations requires an analysis of the factors for

77

663 F.3d 1124 (10th Cir. 2011).

78

Id. at 1132.

79

Id.

80

R. 1207.

81

R. 1215.

19

coverage under the Plan, in contrast to cases in which a claim is “deemed denied” by operation
of law. 82 Thus, the court concludes the Plan grants discretionary authority to ValueOptions, and
an arbitrary and capricious standard applies.
B. Application of arbitrary and capricious standard
Under an arbitrary and capricious standard, the court’s review “is limited to determining
whether the interpretation of the plan was reasonable and made in good faith.” 83 The decision to
deny benefits “need not be the only logical one nor even the best one. It need only be sufficiently
supported by facts within [the plan administrator’s] knowledge to counter a claim that it was
arbitrary or capricious.” 84 The court should uphold the plan administrator’s decision if it “fall[s]
somewhere on a continuum of reasonableness—even if on the low end.” 85
Plaintiff argues ValueOptions’s decision to deny the request for services was arbitrary
and capricious because (1) the claims were not reviewed by physicians with the appropriate
medical expertise, and (2) it did not provide a full and fair review by taking into account
information submitted by Plaintiff.
1. Medical specialty of reviewing physicians
Plaintiff argues the ValueOptions and Allmed reviewers did not have a medical specialty
or expertise comparable to M.K.’s treating physicians, and therefore their opinions did not
provide a reasonable basis for the denials.
Under 29 C.F.R. § 2560.503-1(h)(3)(iii), a plan administrator must consult with “a health
care professional who has appropriate training and experience in the field of medicine involved

82

See Gilbertson v. Allied Signal, Inc., 328 F.3d 625, 631 (10th Cir. 2003).

83

LaAsmar, 605 F.3d at 796 (citation omitted).

84

Kimber v. Thiokol Corp., 196 F.3d 1092, 1098 (10th Cir. 1999) (citation omitted).

85

Id. (alteration in original) (citation omitted).

20

in the medical judgment.” Plaintiff argues ValueOptions’ first reviewer, identified only as a
doctor, and its second reviewer, identified as a psychiatrist specializing in behavioral medicine,
did not have the training and experience in the relevant field of medicine for M.K.’s treatment.
Plaintiff also argues the preparer of the Allmed report, who was listed as a psychiatrist with
specialties in geriatric psychiatry and addiction medicine, was not qualified to provide an opinion
on adolescent treatment. Plaintiff contends ValueOptions’ failure to satisfy Section (h)(3)(iii)’s
requirements is “so serious that [ValueOptions] forfeits the deferential standard of review to
which a fiduciary may otherwise be entitled.” 86
Even assuming the identification and expertise of the reviewers did not satisfy Section
(h)(3)(iii)’s requirements, the court concludes ValueOptions has substantially complied with
ERISA and thus does not forfeit the deferential standard of review. ValueOptions has provided
evidence that all three reviewers were psychiatrists, and Plaintiff has pointed to no authority that
would require a more specific area of expertise in order to review an adolescent’s claim. Thus,
ValueOptions has substantially complied with Section (h)(3)(iii), and the arbitrary and capricious
standard of review applies.
2. Full and fair review
Plaintiff argues ValueOptions did not take into account evidence she provided about
M.K.’s condition and therefore did not provide a full and fair review.
ERISA plans are required to “afford a reasonable opportunity . . . for a full and fair
review by the appropriate named fiduciary of the decision denying the claim.” 87 A full and fair
review means “knowing what evidence the decision-maker relied upon, having an opportunity to

86

Dkt. 30 at 35.

87

Sandoval, 967 F.2d at 381 (alteration in original) (citing 29 U.S.C. § 1133(2)).

21

address the accuracy and reliability of the evidence, and having the decision-maker consider the
evidence presented by both parties prior to reaching and rendering his decision.” 88 The review
must take into account “all comments, documents, records, and other information submitted by
the claimant relating to the claim, without regard to whether such information was submitted or
considered in the initial benefit determination.” 89 However, a full and fair review does not
require “the taking of particular steps in response to a claimant’s challenge or . . . a detailed
explanation thereof in an appeal denial letter.” 90 In other words, a plan administrator need not
explain “the reasoning behind the reasons.” 91
The Plan in this case provides six criteria for admission to RTC services, including
whether the patient is “not sufficiently stable,” can “respond favorably” to counseling and
training, has “a history of poor treatment adherence or outcome,” or has options for lower levels
of care that are “appropriate to meet the individual’s needs.” 92 The Plan lists eleven criteria for
“continued stay” at an RTC, including whether the treatment is “appropriate to the individual’s
changing condition,” care is rendered in “a clinically appropriate manner,” and the family is
“actively involved in the treatment.” 93 Plaintiff argues ValueOptions ignored M.K.’s behaviors
while at Aspen that met all of these criteria, including having auditory and visual hallucinations,
attempting to choke herself with the thread of an unraveled glove, scratching herself on the arm,

88

Sage v. Automation, Inc. Pension Plan & Tr., 845 F.2d 885, 893–94 (10th Cir. 1988) (citation omitted).

89

Adamson v. Unum Life Ins. Co. of Am., No. 2:98-CV-0286-TS, 2001 WL 35816762, at *6 (D. Utah May 30,

2001) (citing 29 C.F.R. § 2560.503–1(h)(2)(iv)).
90

Niedens v. Cont’l Cas. Co., 258 F. App’x 216, 220 (10th Cir. 2007).

91

Flinders v. Workforce Stabilization Plan of Phillips Petroleum Co., 491 F.3d 1180, 1192 (10th Cir. 2007).

(abrogated on other grounds by Spradley v. Owens-Illinois Hourly Emps. Welfare Ben. Plan, 686 F.3d 1135 (10th
Cir. 2012)) (citation omitted).
92

R. 87.

93

R. 88–89.

22

stuffing paper in her ears in an attempt to “keep the voices out,” and attempting to choke herself
with weather stripping from a window.
The record shows ValueOptions took these reports into account but did not conclude they
required RTC services. The initial reviewing physicians focused on M.K.’s behavior after her
discharge from the hospital, which would have provided the basis for RTC admission. One
physician noted that between her discharge and her admission to Aspen, M.K. had only one
instance of self-injurious behavior. 94 The physician’s report stated that, even given this event,
which involved M.K. using a knife to scratch her arms, she could have remained at home.
Additionally, the Allmed physician reviewed all of M.K.’s records from Aspen and determined
the criteria for RTC services were not met because the instances of M.K.’s self-injurious
behavior were “superficial at best and did not require 24-hour intense supervision to control.” 95
The criteria for admission to RTC services and continued stay are highly subjective.
ValueOptions’ determination that M.K. did not meet these criteria relied on the physicians’ welldetailed reports about M.K.’s history of treatment and other available options. The contrary
report from M.K.’s outpatient therapist—who provided therapy to M.K. only until 2012—
evinces a difference of opinion concerning the criteria, but does not show the medical opinions
ValueOptions relied upon were unreasonable. Thus, the court concludes ValueOptions provided
a full and fair review of Plaintiff’s claim.

94

R. 989.

95

R. 1037.

23

While Plaintiff certainly had grounds for believing M.K. satisfied the criteria, the court
cannot say that ValueOptions’ denials were not based on any reasonable basis. 96 Thus, the court
must affirm ValueOptions’ denial of coverage. The Clerk of Court is directed to close the case.
CONCLUSION
The court concludes that Plaintiff’s action was timely filed. However, ValueOptions’
denial of benefits was reasonable. Thus, Plaintiff’s Motion for Summary Judgment is
DENIED, 97 and ValueOptions’ Motion for Summary Judgment is GRANTED. 98
SO ORDERED this 25th day of September, 2018. The Clerk of Court is directed to close the
case.
BY THE COURT:

________________________________________
ROBERT J. SHELBY
United States District Judge

96

The fact that ValueOptions used nearly the same language in its two denials does not alter this conclusion. The

physicians’ decisions were detailed in their treatment reports, and the letter informed Plaintiff she could request
copies of those reports.
97

Dkt. 30.

98

Dkt. 29.

24