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Adele E. v. Anthem Blue Cross and Blue Shield

United States District Court, D. Maine

August 6, 2015

ADELE E., Plaintiff



The plaintiff, Adele E., seeks to modify the record and conduct discovery in this action, brought pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., to obtain medical benefits from a group health plan insured and administered by the defendant, Anthem Blue Cross and Blue Shield (“Anthem”). See Plaintiff’s Motion To Modify the Administrative Record and for Discovery (“Motion”) (ECF No. 18) at 1.

For the reasons that follow, I grant the Motion in part with modifications, and deny it in part.[1]

I. Factual Background

The plaintiff alleges the following, in relevant part.

The plaintiff was at all relevant times a covered beneficiary under the Elmina B. Sewall Foundation employee health benefit plan (“Plan”). Complaint (ECF No. 1) ¶ 4. Benefits under the Plan are insured and administered by Anthem. Id. ¶ 5.

The plaintiff, who resides in Freeport, Maine, is a 23-year-old woman with a history of severe mental illnesses, including bulimia nervosa and obsessive compulsive disorder. Id. ¶¶ 3, 6. On or about May 29, 2012, she was admitted to RainRock Treatment Center (“RainRock”), a residential treatment center in Eugene, Oregon, for treatment of her severe mental illnesses. Id. ¶ 7. The defendant denied benefits for treatment at RainRock effective June 18, 2012, on the ground that the plaintiff’s treatment was no longer “medically necessary.” Id. ¶ 8. The plaintiff remained at RainRock until October 29, 2012. Id. ¶ 9.

On February 15, 2013, the plaintiff appealed the defendant’s decision to terminate her benefits. Id. ¶ 10. The defendant denied the appeal on or about March 14, 2013. Id. ¶ 11. The plaintiff submitted a second-level voluntary appeal on or about August 8, 2013. Id. ¶ 12. The defendant denied that appeal on or about November 26, 2013. Id. ¶ 13. The plaintiff incurred the cost of her treatment at RainRock from June 18, 2012, through October 29, 2012. Id. ¶ 14. The plaintiff filed this action on January 2, 2015, challenging the defendant’s allegedly wrongful termination of benefits for treatment at RainRock. Id. ¶¶ 15-24.

II. Request To Modify Record

The plaintiff seeks to modify the record to add (i) benefit plan and related documents, (ii) documents regarding the denial of her second-level appeal, and (iii) information regarding medical reviewers. See Motion at 5-9. The first and third categories are also the subject of her proposed requested discovery. See Plaintiff’s Requested Discovery (“Requested Discovery”) (ECF No. 18-1), attached to id. For the reasons discussed below, I grant, with modifications, the plaintiff’s request to supplement the record as to the benefit plan and related documents, grant, without objection, her request to supplement the record with materials pertaining to her second-level appeal, and grant her request to supplement the record with medical reviewer information only insofar as it implicates documents responsive to a proposed request for production of medical reviewers’ curriculum vitae, and otherwise deny it.

A. Benefit Plan and Related Documents

The plaintiff first seeks to modify the record to add “any Plan documents, summary plan descriptions, certificates of coverage, insurance policies, booklets, pamphlets or other documents which (a) summarize or describe the benefits to be paid pursuant to the Plan, (b) are potentially applicable to Plaintiff’s claim for benefits, and (c) are not already contained in the record as produced by Defendant[.]” Motion at 6. She explains that she believes that the certificate of coverage that is already of record accurately explains the benefits and obligations under the applicable Plan but that a certificate of coverage is not a plan document or summary plan description (“SPD”), as those documents are defined by ERISA. See id. She states that the purpose of her request is to avoid surprise by ensuring that all relevant Plan documents are produced at the outset of this action. See id.

The defendant argues that the Motion should be denied in toto, see Opposition at 1-2, but agrees, in the context of discussing related proposed discovery requests, to produce an SPD if the summary of benefits contained in the certificate of coverage does not constitute an SPD, as well as behavioral health and clinical guidelines in effect at the time the claims arose regarding the “medical necessity criteria” relating to the treatment of psychiatric and substance-related disorders (including eating disorders), see Id. at 1-2, 5-7.

As this court has noted, “claimants have a right to discover the contents of the administrative record if they are unsure whether all relevant information has been included[.]” Grady v. Hartford Life & Accident Ins. Co., Civil No. 08-339-P-H, 2009 WL 700875, at *6 (D. Me. Mar. 12, 2009). “[A] claimant is entitled, ‘upon request and free of charge, [to] reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits[.]’” Id. (quoting 29 C.F.R. § 2560.503-1(h)(2)(iii)). See also, e.g., Ganem v. Liberty Life Assurance Co. of Boston, No. 1:12-CV-00128-GZS, 2012 WL 5464604, at *4 (D. Me. Nov. 9, 2012) (“Clearly, [a claimant] has a right to access and utilize in her merits ...

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