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Anonymous Oxford Health Plan Member With ID #6023604*01 v. Oxford Health Plans

March 16, 2009

ANONYMOUS OXFORD HEALTH PLAN MEMBER WITH ID #6023604*01, ON BEHALF OF HIMSELF AND ALL OTHERS SIMILARLY SITUATED, PLAINTIFF,
v.
OXFORD HEALTH PLANS (NY), INC., A NEW YORK CORPORATION, UNITED HEALTHCARE SERVICES, INC., A MINNESOTA CORPORATION, AND UNITED HEALTHCARE, INC., A DELAWARE CORPORATION, DEFENDANTS.



The opinion of the court was delivered by: Honorable Paul A. Crotty, United States District Judge

OPINION & ORDER

Plaintiff, an anonymous employee of the law firm of Entwistle & Cappucci, LLP, sues Defendants Oxford Health Plans (NY), Inc. ("Oxford"), United HealthCare Services, Inc. ("UHSI"), and United HealthCare Inc. ("UHI"), to recover benefits under the Employee Retirement Income Security Act of 1974 ("ERISA") § 502(a)(1)(B), codified at 29 U.S.C. § 1132(a)(1)(B). Plaintiff brings this case as a class action, suing on behalf of himself and all others who were wrongfully denied benefits for hospitalization for mental illness. Defendants move to dismiss the Class Action Complaint pursuant to Federal Rule of Civil Procedure 12(b)(6). For the reasons that follow, the Defendants' motion to dismiss the Complaint is GRANTED.

BACKGROUND*fn1

Plaintiff's daughter was covered under her father's health insurance plan, issued by Oxford. The daughter received inpatient treatment on two separate occasions for an eating disorder at what Plaintiff calls a "residential" treatment facility. The first occasion was in May and June of 2004 at The Renfrew Center in Philadelphia. The second occasion was in July and August of 2006 at the Klarman Center at McLean Hospital in Massachusetts. Both treatment centers are not "in-network" institutions under Plaintiff's health plan. On both occasions Oxford denied coverage for the Plaintiff's health expenses.*fn2

In denying the claim for the 2006 treatment, Oxford sent Plaintiff a letter stating that the basis for the denial was that "Resident[i]al mental health is not a covered benefit." (See Complaint ("Compl.") ¶ 36.) On appeal, the Medical Director denied the claim because "inpatient mental health coverage is only available from in-network providers" and McLean Hospital was not in-network. (Id. ¶ 42.) Oxford's reasons for denying the claim for the 2003 treatment were substantially similar. (Id. ¶ 51.) Plaintiff alleges that Oxford wrongfully denied his claims in both cases. In the alternative, Plaintiff argues that the Oxford health plan contained ambiguities that should be construed against Oxford, the drafter of the plan.

I. Plaintiff's Health Plan

Each year, Oxford issued Plaintiff a Certificate of Coverage (the "Certificate"), which details the plan's coverage. Each Certificate contains an integration clause, identifying all the documents that make up the agreement between Plaintiff's employer and Oxford. As an example, the integration clause in the 2003 Certificate says:

1. Entire Agreement

This Certificate, the HMO Certificate, the Freedom Plan Summary of Benefits, any Certificate riders issued to and accepted by the Group, the Group Enrollment Agreements, and the individual applications of you and your Covered Dependents, if any, constitute the entire contract between the parties. (See Declaration of Rodney Lippold ("Lippold Decl.") Ex. F at 2003 Cert 092.) The Court finds that the integration clause requires that the plan documents be read together, not separately, to understand the nature of the coverage.*fn3

a. The 2003 Certificate

The 2003 Certificate was in effect when the Plaintiff's daughter received treatment at the Renfrew Center in 2004. The 2003 Certificate instructs participants to "check your Summary of Benefits" to see if mental health services were added through a rider. (See Id. Ex. F at 2003 Cert 034.) The 2003 Certificate also states that any changes to coverage "will be made by rider." (Id. at 2003 Cert 042.)

The 2003 Certificate has a rider titled "Mental Health and Substance Abuse Rider." ("2003 Rider") (Id. at 2003 Cert 097.) This single rider contains a section on coverage for mental health services for both inpatient and outpatient care. Under the "Inpatient" section, the rider states that:

We Cover Inpatient and Equivalent Care for the treatment of mental or nervous disorders. We define "Inpatient Care" to mean treatment provided in a hospital as defined below. "Equivalent Care" is provided in a setting, other than such hospital, that We and the Provider deem to be safe and medically appropriate. . . .

Inpatient and Equivalent Care mental health services are Covered only when obtained from facilities licensed by the appropriate state regulatory authority as well as any other Provider We deem appropriate to provide the Medically Necessary level of care. Alcoholism and substance abuse related ...


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