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Michael Edgar v. Mvp Health Plan

May 6, 2011


The opinion of the court was delivered by: Gary L. Sharpe District Court Judge


I. Introduction

Plaintiff Michael Edgar brought this action against defendant MVP Health Plan, Inc. under § 502(a)(1)(B) of the Employment Retirement Income Security Act (ERISA), 29 U.S.C. § 1132(a)(1)(B), seeking to recover medical fees incurred as a result of MVP's denial of benefits due under the health insurance services plan administered by MVP. (See Compl., Dkt. No. 1.) Pending are MVP's motion for summary judgment, (Dkt. No. 19), and Edgar's cross-motion for summary judgment, (Dkt. No. 23). For the reasons that follow, MVP's motion is granted and Edgar's motion is denied.

II. Background

A. Factual History

MVP Health Plan, Inc. is a New York State not-for-profit corporation that is authorized to issue health maintenance organization insurance products to groups and individuals within MVP's services area. (See Def. SMF ¶ 1, Dkt. No. 19:1.) In September 2007, Edgar Roofing/Sheet Metal and MVP entered into a New York State Health Insurance Contract (the Plan), which provides Edgar Roofing's eligible employees and their dependents with certain health care benefits. (See Pieraccini Aff., Def. Ex. A at 1-87, Dkt. No. 19:4 (filed under seal).) As a dependent of James Edgar, an Edgar Roofing employee, plaintiff Michael Edgar was an eligible beneficiary of the Plan. (See Def. SMF ¶ 4, Dkt. No. 19:1.) The Plan constitutes an employee welfare benefit plan under ERISA as defined by 29 U.S.C. § 1002. (See id. at ¶ 3.)

The Plan consists of the following documents: (1) the General Terms and Conditions; (2) the Certificate of Coverage; (3) the Mental Health Parity-Extended Benefits Rider; (4) the Contraceptive Drug & Devices Rider; (5) the Schedule of Benefits; (6) the Premium Rate Schedule; and (7) the Group Application. (See id. at ¶ 5.) The Certificate, as amended by the Mental Health Parity Rider and the Contraceptive Drug & Devices Rider, describes the health care services covered under the Plan and the terms and conditions according to which benefits for such services are provided. (See id. at ¶ 6.) The Certificate stipulates that MVP will provide benefits for services that are both "Covered," (see Pieraccini Aff., Def. Ex. A at 19, Dkt. No. 19:4), and "Medically Necessary," (see id. at 52). "Covered Services" are defined as "the health care services specified in th[e] Certificate as eligible for benefits." (Id. at 21.) According to the Certificate, services are "Medically Necessary" if (1) they are recommended by the beneficiary's treating professional provider; and (2) MVP's Medical Director or physician designee determines that they meet the following criteria:

i. the services are appropriate and consistent with the diagnosis and treatment of [the beneficiary's] medical condition;

ii. the services are not primarily for [the beneficiary's] convenience, the convenience of [his] family, or [his] provider;

iii. the services are required for the direct care and treatment or management of that condition;

iv. the services are provided in accordance with general standards of good medical practice, as evidenced by, reports in peer reviewed medical literature; reports and guidelines as published by nationally recognized health care organizations that include supporting scientific data; and other relevant information brought to [MVP's] attention; and

v. the services are rendered in the most efficient and economical way and at the most economical level of care, which can safely be provided to [the beneficiary].

(Id. at 52.) By way of the Mental Health Parity Rider amendment, a sixth criterion requires that "the services are expected to provide significant, measurable clinical improvement within a reasonable and medically predictable period of time." (Id. at 80.)

The Certificate generally states that "MVP will only provide benefits for Covered Services provided by an MVP Participating Provider."*fn1 (Id. at 19.) However, the Certificate outlines three 'exceptional circumstances' in which MVP will provide benefits for services provided by out-of-network providers: (1) covered emergency care services;*fn2 (2) covered non-emergency services where the "Covered Services" required are not available through an MVP Participating Provider and where the beneficiary receives prior written approval from MVP's Utilization ...

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