United States District Court, D. Maine
ANXO CEREIJO ROIBAS, as assignee of Melissa True, and MELISSA TRUE Plaintiffs,
EBPA, LLC, d/b/a/ Employee Benefit Plan Administration, and MAINEGENERAL HEALTH, Defendants.
ORDER ON CROSS-MOTIONS FOR JUDGMENT ON THE
TORRESEN UNITED STATES CHIEF DISTRICT JUDGE
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” or the
“administrator”) (ECF No. 48).
For the reasons set out below, I DENY the
Plaintiffs' motion and I GRANT
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. 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.
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
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.
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.
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.
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.
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
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)).
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.”Consent Mot. to
Am. Scheduling Order ¶ 5 (ECF No. 42). 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