Denial of Health Insurance Benefits and Attorney's Fees Upheld on Appeal
In Doe v. Harvard Pilgrim Health Care, Inc.
, 2020 WL 5405367 (1st
Cir. 2020), the First Circuit Court of Appeals upheld the decision of the U.S. District Court of Massachusetts that Harvard Pilgrim appropriately denied benefits for residential mental health treatment. The First Circuit also upheld the District Court’s decision denying an award of attorney’s fees to the plaintiff for achieving an earlier remand of the case.
Doe was a dependent beneficiary in a group health benefit plan provided by Doe’s father’s employer. The plan was funded by a policy issued by Harvard Pilgrim. The plan provided coverage for in-patient care, intermediate care, and outpatient mental health care only to the extent medically necessary. The plan utilized strict guidelines to determine whether residential mental health treatment was necessary. Doe sued after her claim for residential mental health treatment was partially denied.
The case has a somewhat convoluted procedural history. The District Court initially upheld Harvard Pilgrim’s decision in 2017. Doe appealed and the First Circuit remanded the case on the grounds that the administrative record should have been expanded. The District Court then did so and, after allowing additional briefing and argument, again found that Doe had not met her burden to show that she was entitled to coverage for residential treatment during the disputed period. Doe appealed again.
Noting that in its prior decision it had held that under the de novo standard of review, the District Court’s factual findings would be reviewed only for clear error, the First Circuit found none. While Doe attacked Harvard Pilgrim’s expert reports, the First Circuit found that there was no clear error for the District Court to rely on those reports or read them in the manner suggested by Doe.
Doe also argued that the District Court should have had a bench trial and required the various experts to testify and be subject to cross-examination. The First Circuit stated that such a proposal had long ago been rejected in its decision in Orndorf v. Paul Revere Life Ins. Co.
, 404 F.3d 510 (1st
Cir. 2005). The court reiterated that it has consistently held that the record before the District Court should match the record reviewed by the administrative decision maker absent special circumstances.
Lastly, the First Circuit upheld the District Court’s denial of Doe’s request for attorney’s fees for the period leading up to the First Circuit’s initial decision remanding the case back to the District Court. The First Circuit reviewed the five-factor test it has repeatedly utilized to consider an award of attorney’s fees and found the District Court made no legal or clear factual error in the exercise of its discretion that attorney’s fees were not warranted in a case where the plaintiff’s “success on the merits” was limited to only achieving a remand to the District Court.
The First Circuit affirmed the decision of the District Court.