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Roibas v. EBPA, LLC

United States District Court, D. Maine

September 28, 2018

ANXO CEREIJO ROIBAS, as assignee of Melissa True, and MELISSA TRUE Plaintiffs,
v.
EBPA, LLC, d/b/a/ Employee Benefit Plan Administration, and MAINEGENERAL HEALTH, Defendants.

          ORDER ON CROSS-MOTIONS FOR JUDGMENT ON THE ADMINISTRATIVE RECORD

          NANCY TORRESEN UNITED STATES CHIEF DISTRICT JUDGE

         The parties to this action dispute the terms of the MaineGeneral Health Employee Health Plan (the “Plan”), of which Plaintiff Melissa True is a beneficiary. The Plan is governed by the Employee Retirement Income Security Act (“ERISA”). This matter comes before me on cross-motions for judgment on the administrative record filed by the Plaintiffs (ECF No. 50) and by Defendant MaineGeneral Health (“MaineGeneral” or the “administrator”) (ECF No. 48). For the reasons set out below, I DENY the Plaintiffs' motion and I GRANT MaineGeneral's motion.

         THE PARTIES

         Plaintiff True is an employee of MaineGeneral and a beneficiary of the Plan. Plaintiff Roibas is an assignee of True's rights to reimbursement of medical expenses for services covered by the Plan. AR 327, 339.[1] Defendant MaineGeneral is the Plan administrator, responsible for selecting the terms of the Plan and interpreting them. AR 93. Defendant EBPA is the third party administrator of the Plan and conducts the administrative, “ministerial, ” operations, such as processing claims. See AR 93, 102.[2]

         FACTUAL BACKGROUND

         In August of 2014, Melissa True entered into a “Gestational Carrier Agreement” (the “Agreement”) with intended parents Anxo Cereijo Roibas and Szczepan Wojciech (the “Intended Parents”). AR 329. The Agreement provided that True would “carry and deliver the child(ren) of the Intended Parents . . . through medical procedures using assisted reproductive technology.” AR 329-30. True was to be compensated for serving as a gestational carrier. AR 341-42. The Intended Parents also committed to “pay all medical expenses which are reasonably and directly related to the pregnancy and birth which are not covered by [True's] health insurance.” AR 339 (emphasis added). True agreed to submit claims for all pregnancy-related medical expenses to her health insurer and to assist the Intended Parents in seeking to have the expenses covered, including through “all available administrative and legal remedies” if the insurer denied the claims. AR 331-32.

In a section titled, “Medical Covered Expenses, ” the Plan lists,
[c]harges for maternity care including prenatal, delivery, and postpartum care as well as charges arising from complications that may occur during maternity and delivery. Comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period are payable at 100% at the applicable benefit level.

AR 027. The next section of the Plan is titled, “General Medical Exclusions and Limitations, ” and lists, “[e]xpenses for surrogacy.” AR 032.

         True became pregnant and gave birth, in accordance with the Agreement. Medical expenses from the pregnancy and delivery were submitted to EBPA. AR 110-84; 299. EBPA initially approved, and paid for, some expenses related to True's pregnancy. See AR 110-21, 127-29, 134-36, 146-52, 299. Upon review of True's claims and medical records, a utilization review nurse employed by EBPA identified that True was a surrogate mother and that, accordingly, her claims should be denied because they were not covered by the Plan. AR 299.

         PROCEDURAL BACKGROUND

         True appealed the denial of her claims in a letter to EBPA dated January 20, 2016. She stated that the “main[]” basis of her appeal was that she “was informed there would not be any issues related to claims for prenatal care” during a call to EBPA in January 2015, in which she inquired “to determine if EBPA had maternity coverage for surrogacy related pregnancies.” AR 301. True claimed in the letter that she was informed on that call that “there was no exclusion, [and] that pregnancy was a covered diagnosis.” AR 301. After communicating with MaineGeneral, EBPA denied True's appeal, claiming that it had no record of the phone call that she referenced. AR 302. EBPA further informed her that “[verification can only be documented in your file when you had actual medical coverage” and that “a verification of benefits is not a guarantee of coverage.” AR 302.

         True, with the assistance of counsel, filed a second administrative appeal in April of 2016, arguing that “[t]he Plan does not distinguish between pregnancies based upon why the woman became pregnant.” AR 304. True also argued that she served as a gestational carrier, rather than a surrogate, that “[t]he Plan does not state that expenses for a ‘gestational carrier' are excluded, ” and that any ambiguity in the Plan should be construed in favor of coverage. AR 305. EBPA denied this appeal in a letter dated May 4, 2016. AR 318-19. The basis for the denial was that “True's denied claims fall under the surrogacy exclusion as outlined in the [Plan], ” and that, to the extent that True was a gestational carrier and not a surrogate, the Plan excludes “[e]xpenses for any service, procedure or supply not listed as a covered service in the [P]lan.” AR 318.

         Roibas filed a Complaint in this court on January 19, 2017. Roibas claimed standing to challenge the administrator's denial of claims as True's assignee. Compl. (ECF No. 1). True was added as a plaintiff to the action on August 3, 2017. Second Am. Compl. (ECF No. 35). The Plaintiffs and MaineGeneral then filed the instant motions for judgment on the record.[3]

         LEGAL STANDARD

         “By cross-moving for judgment based on the administrative record filed in this case, the parties empower the court to adjudicate this case based on that record, resolving any factual as well as legal disputes.” Ellis v. Unum Life Ins. Co. of Am., No. 2:13-CV-00080-JAW, 2014 WL 235212, at *2 (D. Me. Jan. 22, 2014) (citing Bhd. of Locomotive Eng'rs v. Springfield Terminal Ry. Co., 210 F.3d 18, 31 (1st Cir. 2000)).

         The parties have stipulated that the applicable standard of review for MaineGeneral's decision to deny True's benefit claims is whether that decision was “arbitrary, capricious, or an abuse of discretion . . . as established by the Plan and Firestone Tire and Rubber Co. v. Bruch, [489 U.S. 101 (1989)] and its progeny.”[4]Consent Mot. to Am. Scheduling Order ¶ 5 (ECF No. 42).[5] The First Circuit has noted that in this context, “the arbitrary and capricious standard is functionally equivalent to the abuse of discretion standard.” Dutkewych v. Standard Ins. Co., 781 F.3d 623, 633 n.6 (1st Cir. 2015). Under that standard, I “need not decide the ‘best reading' of the Plan.” O'Shea through O'Shea v. UPS Ret. Plan, 837 F.3d 67, 73 (1st Cir. 2016). Instead, I must evaluate whether the administrator's decision “is reasonable and supported by substantial evidence on the record as a whole.” Doe v. Standard Ins. Co., 852 F.3d 118, 123 (1st Cir. 2017). I may not disturb the administrator's reasonable interpretation even if I would have come to a different conclusion or if the Plaintiffs have ...


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