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S.M. v. Oxford Health Plans (Ny), Inc.

United States District Court, S.D. New York

April 1, 2014

S.M., Plaintiff,
v.
OXFORD HEALTH PLANS (NY), INC., a/k/a OXFORD HEALTH INSURANCE, INC., OXFORD HEALTH PLANS LLC, UNITEDHEALTHCARE SERVICES, INC., and UNITEDHEALTH GROUP INCORPORATED, Defendants.

MEMORANDUM AND ORDER

JAMES C. FRANCIS, IV, Magistrate Judge.

Pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. ยง 1001 et seq., the plaintiff seeks federal court review of a 2011 denial of coverage for the drug Gamunex by Oxford Health Plans (NY), Inc. ("Oxford"). The plaintiff has moved to compel discovery from Oxford of five Individual Authorization Reports: for the drug Rituxan in 2011, 2012, and 2013 and for Gamunex in 2012 and 2013.

Background

The plaintiff, known in this case by the initials S.M. pursuant to a protective order, was diagnosed with non-Hodgkin's lymphoma in September 2008. (Memorandum of Law in Support of Plaintiff's Motion to Compel Production of Documents ("Pl. Memo.") at 1). She enrolled in Oxford's Freedom Plan Metro, an employee welfare benefit plan under ERISA, in September 2010. (Defendants' Memorandum in Opposition to Plaintiff's Motion to Compel Production of Documents ("Def. Memo.") at 2). On September 15, 2011, S.M. requested that Oxford cover one year of treatment with Gamunex, an intravenous immunoglobin treatment that helps fight against infection, as prescribed by her treating physician. (Def. Memo. at 4). At the time, she was also being treated with Rituxan, a form of chemotherapy, which was covered by Oxford. (Pl. Memo. at 2).

Oxford's assigned Medical Director, Dr. Bruce Lundblad, reviewed the claim for Gamunex and denied it as not medically necessary. (Def. Memo. at 4). On September 16, 2011, Oxford sent the plaintiff a letter describing the basis for the denial. (Def. Memo. at 5). After the plaintiff appealed the denial, Dr. Lundblad spoke with Dr. Janet Cuttner, the plaintiff's treating physician, regarding the plaintiff's treatment. (Def. Memo. at 5). Dr. Lundblad then changed his initial determination and granted three months of coverage for Gamunex. (Def. Memo. at 5-6).

In November 2011, the plaintiff requested that her coverage be extended until September 2012. (Def. Memo. at 6). Oxford requested additional information on the plaintiff's then-current medical condition, and Dr. Cuttner provided recent progress notes, lab test results, and results from a CT scan. (Def. Memo. at 6). Dr. Lundblad requested further information, and Dr. Cuttner sent an additional letter describing the plaintiff's current condition. (Def. Memo. at 7). Dr. Lundblad then denied the extension of coverage as not medically necessary. (Def. Memo. at 7). After sending notice of the determination, Dr. Lundblad contacted Dr. Cuttner once again. (Def. Memo. at 8). However, the resulting communications did not change Dr. Lundblad's determination. (Def. Memo. at 8). Following the denial, the plaintiff pursued an expedited internal review and an external appellate review. (Def. Memo. at 9).

The plaintiff contends that this pattern of changing determinations is evidence of Oxford's desire "to arrive at a results-driven denial of coverage." (Pl. Memo. at 1). She further argues that Dr. Lundblad, a former family practitioner, was "stunningly unqualified" to determine whether Gamunex was medically necessary and alleges that Oxford deliberately asked him to review the claim in order to pave the road to denial. (Pl. Memo. at 2, 4, 10). Oxford granted the plaintiff's subsequent claims for Gamunex coverage in 2012 and 2013. (Pl. Memo. at 2).

A. Relevant Procedural History

In September 2013, the plaintiff requested permission to conduct limited discovery, in particular the deposition of Dr. Lundblad. (Def. Memo. at 11). The plaintiff sought to depose Dr. Lundblad on three topics: "(1) the process Oxford followed in changing its medical determinations regarding [the] [p]laintiff's entitlement to Gamunex; (2) Oxford's contracts with Dr. Lundblad; and (3) the number of non-Hodgkin's lymphoma patients denied Gamunex nationwide." (Def. Memo. at 11). Following a hearing, the Court granted the plaintiff's request but limited Dr. Lundblad's deposition to the first topic. (Transcript of Hearing dated Oct. 1, 2013, at 30-31). Specifically, the Honorable Edgardo Ramos, U.S.D.J., allowed the plaintiff to depose Dr. Lundblad on Oxford's policies and processes during the time period stretching through "the initial denial, the subsequent grant, and then the later denial some three months later." (Tr. at 30).

At his deposition, Dr. Lundblad described the clinical information he considered when making his initial denial, the decision to grant three months coverage, and the final denial. Dr. Lundblad testified that he was unaware that the plaintiff was taking Rituxan when she requested coverage for Gamunex. (Pl. Memo. at 5; Def. Memo. at 13). He further stated that he did not believe that Rituxan was relevant to his determination regarding Gamunex. (Pl. Memo. at 5, 7-8). The plaintiff contends that further discovery is warranted because Dr. Lundblad's testimony was primarily "notable for what he did not know." (Pl. Memo. at 2). In particular, S.M. wants to determine whether the requested records "address the interplay between Rituxan and Gamunex, as the side-effects of Rituxan bear directly on S.M.'s need for Gamunex, " and why Dr. Lundblad did not have this information at his disposal. (Pl. Memo. at 2).

In January 2014, the plaintiff twice requested the production the Individual Authorization Reports[1] at issue: those authorizing coverage for Rituxan in 2011, 2012, and 2013 and Gamunex in 2012 and 2013. (Pl. Memo. at 2; Def. Memo. at 1). The defendants objected to the requests on the grounds that the documents are beyond the administrative record and are irrelevant. (Def. Memo. at 1). S.M. argues that the requested discovery is encompassed within Judge Ramos' order allowing for the deposition of Dr. Lundblad on "the process Oxford followed in repeatedly changing its medical determinations." (Pl. Memo. at 2).

Discussion

A. Legal Standard

ERISA does not mandate a particular standard of review; rather, "the terms of the plan documents determine whether the court should apply an arbitrary and capricious or a de novo standard of review." Hamill v. Prudential Insurance Co. of America, No. 11 CV 1464, 2012 WL 6757211, at *2 (E.D.N.Y. Sept. 28, 2012), report and recommendation adopted, 2013 WL 27548 (E.D.N.Y. Jan. 2, 2013); see Fay v. Oxford Health Plan , 287 F.3d 96, 103-04 (2d Cir. 2002). The standard of review, in turn, has implications for the scope of discovery. Thus, a discussion of the applicable ERISA standard is often "instructive in establishing the scope of discovery, " even if it has not yet been definitively established. Yasinoski v. Connecticut ...


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