DONALD C. COGGINS, JR., District Judge.
Pending before this Court are the parties' Cross-Memoranda In Support of Judgment. ECF Nos. 24, 25, 26. Defendants filed Replies to Plaintiff's Memorandum. ECF Nos. 27, 28. Plaintiff Jason Berdeau alleges that he was a participant in his employer's, Schaeffler Group, USA Inc.'s ("Schaeffler"), self-funded health plan (the "Plan") and that he was entitled to recover benefits pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §1001 et seq. Specifically, Plaintiff alleges that he requested pre-authorization for certain medical procedures and/or services under the Plan and that his pre-authorization request was improperly denied by Defendants as not being medically necessary. Plaintiff alleges a cause of action against both Defendants for recovery of ERISA benefits under 29 U.S.C. § 1132(a)(1)(B) (First Cause of Action).
The parties entered into and filed a Joint Stipulation agreeing: that Plaintiff exhausted all of his administrative remedies under the Plan, to the contents of the administrative record, to the applicable Plan terms, that the Court should apply an abuse of discretion standard of review as to the determination of medical necessity, and that the Court may dispose of Plaintiff's claim based on the Joint Stipulation, the administrative record and the parties' Memoranda In Support of Judgment. ECF 19.
The principal issue before this Court is whether the Plan's final claim decision that the medical procedure and/or service for which Plaintiff sought preauthorization was not Medically Necessary was proper under the abuse of discretion standard of review. Based on the arguments contained in the parties' Memoranda in Support of Judgment, the joint stipulation and the administrative record, the Court finds that the Plan's denial of Plaintiff's request for pre-authorization was proper and not an abuse of discretion.
The Court makes the following findings of fact pursuant to Federal Rule of Civil Procedure 52 based on the administrative record and the parties' Joint Stipulation:
Plaintiff's employer, Schaeffler, established and/or maintained an ERISA governed, self-funded group health plan for the benefit of its employees. AR 64-152. Schaeffler was both the Plan Sponsor and Plan Administrator and at all times acted as the claims fiduciary retaining the right to make final claim determinations under the Plan. AR 80-81, 127, 129, 136. Schaeffler contracted with Defendant Blue Cross Blue Shield of South Carolina ("BCBSSC") to provide administrative claims payment services under the Plan. AR 137. BCBSSC provided administrative claims payment services only and did not assume any financial risk or obligation with respect to claims. As an eligible employee, Plaintiff was a participant in the Plan.
On or about February 24, 2017, McLeod Spine Center at McLeod Regional Hospital ("McLeod") on behalf of Plaintiff, faxed Defendant BCBSSC seeking preauthorization for an anterior lumbar fusion at L5/S1, CPT codes 22558, 22845 and 22853. AR 286-92.
On March 7, 2017, Lena Bretous, M.D., a board-certified medical director at BCBSSC, reviewed Plaintiff's lumbar fusion claim and found that the requested procedure was not medically necessary. AR 319. Dr. Bretous opined:
(AR 319) (footnotes not in original).
On March 7, 2017, McLeod contacted BCBSSC and requested a peer to peer review between Dr. Bretous and McLeod physician, Willie S. Edwards, Jr., concerning the requested lumbar fusion procedure. (AR 822). On March 9, 2017 a telephone peer to peer review took place between Drs. Bretous and Dr. Edwards. (AR 874). Contemporaneous notes of this peer to peer conversation by Dr. Bretous stated:
AR 874.
On or about March 10, 2017, BCBSSC received a fax request for pre-authorization for the approval of durable medical equipment ("DME") known as an osteogenesis stimulator E0748 and a lumbar sacral orthosis L0637 from Palmetto Medical Equipment of Florence. AR 646. On that same date, Dr. Bretous conducted a medical review of the DME claim and found that the DME claim was also not medically necessary. (AR 859). Dr. Bretous found:
AR 859.
On March 10, 2017, BCBSSC wrote Plaintiff, Rakesh P. Chokshi, M.D., and Palmetto Medical Equipment of Florence that Plaintiff's DME claim was denied because it was not medically necessary and investigational. AR 824-35. The letters stated in relevant part:
AR 824.
On March 29, 2017, BCBSSC wrote Plaintiff, Dr. Edwards and McLeod that the request for pre-authorization for the anterior lumbar interbody fusion had been denied because it was not medically necessary. AR 836-49. These letters stated in relevant part:
AR 836-37, 844-45, 847-48.
On April 10, 2017, Plaintiff appealed the denial of the lumbar fusion. AR 302-18. On April 26, 2017, a specialty matched, independent external review was conducted on Plaintiff's claim by board certified orthopedic surgeon Ryan Gocke, M.D. AR 1045-47. Dr. Gocke found:
AR 1045-46.
On April 26, 2017, Michael Lawhead, M.D., a board certified medical consultant with BCBSSC reviewed Plaintiff's anterior lumbar interbody fusion claim and concurred with Dr. Gocke's findings. AR 301. Dr. Lawhead found:
AR 301.
On April 27, 2017, BCBSSC wrote Plaintiff, Dr. Edwards and McLeod that Defendants' denial of the requested lumbar fusion was being upheld on appeal. AR 1048-58.
On May 25, 2017, BCBSSC received a request from Plaintiff's authorized representative for an external review of Plaintiff's requested lumbar fusion claim. AR 918. On July 14, 2017, the Medical Review Institute of America, Inc., an external review organization accredited by the URAC,
AR 807, 809-10 (footnotes not in original).
The Court finds that the Plan terms are clear and unambiguous. The Plan states:
AR 78-79.
AR 76.
AR 90.
AR 102, 106-07.
The parties stipulated that the Court should apply an abuse of discretion standard of review as to the determination of Medical Necessity (as that term is defined in the Plan). ECF 19, Joint Stipulation ¶ 3. Under the Supreme Court's holding in Metro. Life Ins. Co. v. Glenn, 554 U.S. 105 (2008), and the Fourth Circuit's holding in Champion v. Black & Decker, 550 F.3d 353 (4th Cir. 2008), even if the Court were to assume a structural conflict of interest existed in this matter, the conflict does not change the requirement that the Court is to review the decision at issue for an abuse of discretion. Therefore, under Glenn and Champion, a conflict of interest is to be weighed as a factor in determining whether the Plan abused its discretion when it denied Plaintiffs claim. The "conflict of interest" factor "should prove more important (perhaps of great importance) where circumstances suggest a higher likelihood that it affected the benefits decision . . . ." Glenn, 554 U.S. at 117. The factor "should prove less important (perhaps to the vanishing point) where the administrator has taken active steps to reduce potential bias and to promote accuracy, for example, by walling off claims administrators from those interested in firm finances, or by imposing management checks that penalize inaccurate decision making irrespective of whom the inaccuracy benefits." Id. Thus, "[t]he more incentive for the administrator . . . to benefit itself by a certain interpretation of benefit eligibility or other plan terms, the more objectively reasonable the administrator['s] . . . decision must be and the more substantial the evidence must be to support it." Ellis v. Metro. Life Ins. Co., 126 F.3d 228, 233 (4th Cir. 1997).
In the present case, the Court finds that the conflict of interest factor should be given relatively little weight. First, although Schaeffler was both the Plan Sponsor and Plan Administrator and at all times retained the right to make final claims determinations under the Plan, Schaeffler hired BCBSSC, who had no financial risk or obligation with respect to the payment of claims to provide administrative claims payment services under the Plan. AR 80-81, 136-37. See Palmetto Health v. Nucor Corp. Grp. Health Plan, C/A No. 3:17-cv-02807-RMG, 2018 WL 5300187 (D.S.C. 2018) (holding that while it is true that the employer acted as fiduciary, administrator, and the sole-funder of the plan, the role of the conflict did not affect the reasonableness of the decision where the employer adopted the well-reasoned determination of its third-party administrator which lacked a direct financial interest in the matter, citing Champion, at 359). Second, the medical reviews of Plaintiff's claim were conducted by multiple independent, board certified medical experts, including two BCBSSC medical reviewers and two independent orthopedic surgeons, who had no incentive, financial or otherwise, to deny Plaintiff's claim. Additionally, and more significantly, the independent external reviews were blindly assigned to appropriately matched medical specialists, with one of the experts even giving an attestation that he had no conflict of interest in reviewing Plaintiff's claim. AR 1046. Finally, the medical experts reviewing Plaintiff's claim relied on Plaintiff's own medical records and established CAM policies that were referred to in the Plan in the process of reviewing Plaintiff's claim. The Court finds that while a potential structural conflict of interest existed, the safeguards mentioned above mitigated against giving the potential conflict any great weight.
The Court finds that Plaintiff had the burden of proving that the services he was requesting were Medically Necessary and therefore a "Covered Expense" under the terms of the Plan. AR 90. If the claimant satisfied this burden, the burden shifted to the Plan to show that some exclusion applied which precluded payment of benefits. Catledge v. Aetna Life Ins. Co., 594 F.Supp.2d 610 (D.S.C. 2009); see also Band v. Paul Revere, 14 F. App'x 210 (4th Cir. 2001) (a plaintiff has the burden of proving entitlement to benefits the terms of an ERISA plan); Tucci v. First Unum Life Ins. Co., 446 F.Supp.2d 473 (D.S.C. 2006); Fuja v. Benefit Trust Life Insurance Company, 18 F.3d 1405, 1408 (7th Cir. 1994) (ERISA plaintiff has burden of proving coverage); see also Gable v. Sweetheart Company, Inc., 35 F.3d 851, 855-56 (4th Cir. 1994) (ERISA plaintiff bears the burden of proving their employer's ERISA plan contains a promise to provide vested benefits), Lown v. Continental Cas. Co., 238 F.3d 543 (4th Cir. 2001) (applying de novo standard of review holding that insurer properly denied the plaintiff's claim where the plaintiff failed to meet her burden of proving that she was totally disabled under the terms of a long-term disability plan).
The Court finds that the Plan's claim determination was the result of a deliberate, principled reasoning process and was supported by substantal evidence. Under the abuse of discretion standard, an administrator's decision will not be disturbed if it is reasonable, even if the reviewing court would have come to a different conclusion independently. See, e.g., Evans, 514 F.3d at 323; Smith v. Cont'l Cas. Co., 369 F.3d 412, 417 (4th Cir. 2004); Feder v. Paul Revere Life Ins. Co., 228 F.3d 518, 522 (4th Cir. 2000). "[A] decision is reasonable if it is the result of a deliberate, principled reasoning process and if it is supported by substantial evidence." Ellis v. Metro. Life Ins. Co., 126 F.3d 228, 232 (4th Cir. 1997); Bernstein v. CapitalCare, Inc., 70 F.3d 783, 788 (4th Cir. 1995). Substantial evidence is "evidence which a reasoning mind would accept as sufficient to support a particular conclusion" and which "consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance." LeFebre v. Westinghouse Elec. Corp., 747 F.2d 197, 208 (4th Cir. 1984). A reviewing court must assess the reasonableness of the administrator's decision based on the facts known to the administrator at the time of the decision. See, e.g., Elliott v. Sara Lee Corp., 190 F.3d 601, 608-09 (4th Cir. 1999).
A reviewing court may consider various factors to assess the reasonableness of the administrator's decision. These factors include (but are not limited to): (1) the language of the plan; (2) the purposes and goals of the plan; (3) the adequacy of the materials considered to make the decision and the degree to which they support it; (4) whether the fiduciary's interpretation was consistent with other provisions in the plan and with earlier interpretations of the plan; (5) whether the decision-making process was reasoned and principled; (6) whether the decision was consistent with the procedural and substantive requirements of ERISA; (7) any external standard relevant to the exercise of discretion; and (8) the fiduciary's motives and any conflict of interest it may have. Booth v. Wal-Mart Stores, Inc. Assocs. Health & Welfare Plan, 201 F.3d 335, 342 (4th Cir. 2000). The Booth factors are best viewed "as more particularized statements of the elements that constitute a deliberate, principled reasoning process and substantial evidence . . . ." Donnell v. Metro. Life Ins. Co., 165 Fed. Appx. 288, 294 n.6 (4th Cir. 2006) (unpublished) (quotations omitted).
The Court finds that BCBSSC's interpretation of the definition of Medical Necessity and the exclusions contained in the Plan was supported by the Plan's unambiguous language. Subject to ultimate approval by Schaeffler, the Plan clearly gave BCBSSC discretion to determine medical necessity and authorized the use of standards, policies, guidelines, and criteria, including, but not limited to, CAM policies to determine clinically appropriate health care services and generally accepted standards of medical health practice. The Court further finds that BCBSSC's use of the above criteria to interpret clinical determinations and make recommendations regarding the medical necessity and appropriateness of Plaintiff's requested procedure and medical devices was consistent with the terms of the Plan and was not an abuse of discretion. Finally, the Court notes that while Plaintiff alleges that he is entitled to benefits, Plaintiff makes no allegation that BCBSSC misinterpreted the terms of the plan. Accordingly, the Court finds that first Booth factor weighs in Defendants' favor.
The Court finds that the purpose of the Schaeffler Plan was to offer self-funded health coverage to its employees as an employee benefit. Accordingly, the goal of the Plan was to provide a maximum benefit to those covered within the available resources. To meet this goal, the Plan had to be constructed to ensure that claims submitted for covered services were paid. At the same time, the Plan had to be constructed to exclude from coverage other services such as those considered not Medically Necessary and Investigational or Experimental. As can be seen by the definition of Medically Necessary, to be payable, the service had to be in accordance with generally accepted standards, clinically appropriate and not more costly than an alternative service at least as likely to produce equivalent results. Services that were not Medically Necessary and/or were Experimental or Investigational in addition to not being covered were specifically excluded under the terms of the Plan. AR 76, 78-79, 106-107.
In the present case, the evidence in the record, including peer-reviewed standards, policies, guidelines, and criteria; the opinions of two in-house board certified BCBSSC medical reviewers; and two board certified independent specialist medical reviewers determined that Plaintiff's requested procedure and/or DME were not Medically Necessary and/or were Experimental or Investigational. Because the purpose of the Plan was to allow only benefits for services and/or DME that were Medically Necessary and/or not Experimental or Investigational, the Court finds that BCBSSC's recommendation to deny Plaintiff's claim was consistent with the purposes and goals of the Plan.
The Court finds that the Plan's claim determination was supported by substantial medical evidence and was not an abuse of discretion. As was previously discussed, this evidence included peer-reviewed standards, policies, guidelines, and criteria, including CAM policies; the opinions of two in-house board certified BCBSSC medical reviewers; and two board certified independent specialist medical reviewers who all found that Plaintiff's requested procedure and/or DME were not Medically Necessary and/or were Experimental or Investigational.
First, Plaintiff's own objective diagnostic MRI on January 1, 2017, indicated that while Plaintiff had mild DDD with minimum disc protrusion at L5-S1, Plaintiff had no central canal compromise, no canal stenosis and no neural impingement. AR 317. On February 21, 2017, Plaintiff's treating physician, Dr. Edwards, found that Plaintiff had no evidence of instability at L5-S1, had 90 flexion in the lumbar region, had a motor strength 5 out of 5 bilaterally with normal symmetric 2+ reflexes, and had no abnormal gait or long tract findings. AR 313. While Dr. Edwards advocated for Plaintiff to receive the requested lumbar fusion, Dr. Edwards' opinion was not supported by the objective medical evidence. "Courts in the Fourth Circuit routinely hold that it is not an abuse of discretion for an ERISA-regulated plan's claim administrator to deny benefits unsupported by objective evidence." Collins v. Qwest Disability Plan, C/A No. 7:06-cv-1128-HMH, 2006 WL 2946466 (D.S.C. 2006) (internal quotations marks and citation omitted). Accordingly, the Court finds that BCBSSC did not abuse its discretion in failing to give Dr. Edward's opinion controlling weight.
Second, the Court finds that the fact that Dr. Edwards believed that the requested procedure was medically necessary was not binding on the Plan. Under an abuse of discretion standard of review, the Plan was not obligated to give greater weight to the opinions of Plaintiff's treating physicians. Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003); Elliot v. Sara Lee Corp., 190 F.3d 601 (4th Cir. 1999). Plans are not bound by the opinion of a treating doctor in determining medical necessity. See Sheppard & Enoch Pratt Hosp., Inc. v. Travelers Ins. Co., 32 F.3d 120, 125 (4th Cir. 1994) (In determining benefits, "the very judgment of the treating doctor as to the medical necessity of the prescribed treatment is being assessed by the Plan administrator and its medical consultants. To require the Plan to give conclusive weight to the opinion of the treating physician would deprive it of its role in determining medical necessity"); Free v. Travelers Ins. Co., 551 F.Supp. 554, 560 (D. Md. 1982) ("the plaintiff's unfettered right to select a physician and follow his advice does not create a corresponding responsibility in the defendant to pay for every treatment so chosen . . . [t]o require insurers to pay for every remedy, proven or unproven, prescribed by a physician, could invalidate the actuarial basis of current premium rates"); Unlike the opinions of the independent medical reviewers, the BCBSSC in-house medical reviewers and the BCBSSC CAM policies, Dr. Edward's opinion was merely conclusory and failed to address the requirements of the Plan's definition of Medically Necessary and address the required Plan criteria. Therefore, the Court finds that BCBSSC did not abuse its discretion in failing to give Dr. Edward's opinion controlling weight.
Third, the Court finds that the Plan did not abuse its discretion in giving greater weight to the opinions of the two independent, board certified orthopedic surgeons, Dr. Gocke and the medical reviewer from Medical Review Institute of America, who both opined that the requested DME and/or services were not medically necessary and/or were investigational. See AR 806-812, 1045-1047. These reviewers were neutral, appropriately matched specialists who properly applied the terms of the Plan and the applicable plan criteria. The Court finds that BCBSSC's recommendation giving these opinions greater weigh was not an abuse of discretion.
Fourth, the Court finds that the Plan did not abuse its discretion in relying on the opinions of BCBSSC's own board certified medical reviewers, Drs. Bretous and Lawhead. See AR 301, 319, 859, 874. Both Drs. Bretous and Lawhead reviewed Plaintiff's medical records and applied the terms of the Plan and the Plan authorized peer-reviewed standards, policies, guidelines, and criteria, including CAM policies to come to the conclusion that Plaintiff's requested procedure and DME were not medically necessary. Because the Plan was self-funded and BCBSSC was not the insurer of the Plan, the Court finds that Drs. Bretous and Lawhead were neutral experts. Accordingly, the Court finds that the Plan's reliance on Drs. Bretous' and Lawhead's opinions and the applicable BCBSSC CAM policies was not an abuse of discretion. See Martin v. Blue Cross Blue Shield of Virginia, 115 F.3d 1201 (4th Cir. 1997) (upholding the denial of benefits for high dose chemotherapy and peripheral stem cell rescue as being experimental based in part on a Blue Cross Blue Shield of Virginia TEC assessment); Evans v. Blue Cross Blue Shield of South Carolina, 834 F.Supp. 887 (D.S.C.1993) (upholding the denial of benefits for a radial keratotomy based on a BCBSSC TEC assessment and the opinion of BCBSSC's Medical Director).
Fifth, the Court finds that BCBSSC did not abuse its discretion in choosing between conflicting medical evidence. The Fourth Circuit has held it is not an abuse of discretion for a plan fiduciary to deny benefits where conflicting medical reports are presented. Elliot, 190 F.3d 601 (4th Cir. 1999); Ellis v. Metropolitan Life Ins. Co., 126 F.3d 228 (4th Cir. 1997) (finding no abuse of discretion in fiduciary's denial of benefits where claimant's primary medical provider's finding of disability conflicted with reports of independent panel of medical specialists); Brogan v. Holland, 105 F.3d 158 (4th Cir.1997) (affirming district court's grant of summary judgment for trustees where medical evidence was conflicting as to whether the plaintiff's stroke occurred during course of employment). The Court finds that the fact that BCBSSC gave more weight to the objective medical findings; the opinions of two independent, board-certified orthopedic surgeons; the opinions of two board-certified in-house medical reviewers and peer-reviewed CAM policies; all of which specifically addressed the terms of the Plan and the Plan criteria; over the conclusory opinions of Plaintiff's treating physician was not an abuse of discretion.
Additionally, the Court finds that Plaintiff did not engage in sufficient physical therapy to meet the Plan's medical necessity criteria. The Plan's Medical Necessity criteria required that Plaintiff attempt at least 6 weeks of physical therapy. AR 319, 614, 1262-64. However, Plaintiff stated that she engaged in physical therapy from March 23, 2017, through April 5, 2017, ECF 26 at 4, and the records of Hartsville Physical Therapy and Rehabilitation Center indicated that Plaintiff engaged in 22 days of physical therapy from March 14, 2017, through April 5, 2017, AR 933-37. While it is undisputed that Plaintiff did engage in some physical therapy, the Court finds that Plaintiff did not engage in 6 weeks of physical therapy as was required by the Plan criteria.
Likewise, the Court further finds there was substantial evidence in the record that Plaintiff did not complete the required course of pain management injections. According to the evidence in the administrative record, Plaintiff received one epidural steroid injection on February 8, 2017. AR 942. No other steroid injections were noted in the record. Accordingly, the Court finds that Plaintiff failed to meet the required 6 weeks of conservative care required by the criteria. AR 614, 1262-64.
The Court also finds there was no evidence in the administrative record that Plaintiff's daily activities were impaired for 6 months or that Plaintiff suffered significant functional impairment for 3 months which also were requirement of the Medical Necessity criteria. AR 614, 1262-64.
The Court notes that while there was some variation in the opinions of the reviewing physicians as to which particular criteria Plaintiff met, all of the reviewing physicians unanimously found that Plaintiff failed to meet the required combination of Medical Necessity criteria for the requested procedure and durable medical equipment to be covered by the Plan. The fact that BCBSSC chose to give greater weight to a particular finding contained in one or more of these opinions did not amount to an abuse of discretion. See Elliot, 190 F.3d 601 (4th Cir. 1999) (it is not an abuse of discretion for a plan fiduciary to deny benefits where conflicting medical reports are presented).
Plaintiff argues that he should prevail based on the Fourth Circuit's holding in DuPerry v. Life insurance Co. of N. Am., 632 F.3d 860 (4th Cir. 2011). However, the Court disagrees and finds that Plaintiff's reliance on DuPerry is misplaced because DuPerry can be easily distinguished. First, DuPerry involved a claim for long term disability benefits due to fibromyalgia, and not a claim for determining medical necessity based on established medical necessity criteria. Second, the claim administrator in DuPerry was also the insurer of the plan. Therefore, the Fourth Circuit found that this conflict of interest weighed heavily against LINA. Here, although Defendant Schaeffler was both the Plan Sponsor and Plan Administrator and at all times retained the right to make final claims determinations under the Plan, Schaeffler hired BCBSSC, who had no financial risk or obligation with respect to the payment of claims, to provide administrative claims payment services under the Plan. AR 80-81, 136-37. Accordingly, the structural conflict of interest in the present case did not weigh heavily against Defendants. Third, in DuPerry, the Court found that LINA's medical reviewers' opinions ignored the plaintiff's subjective complaints of pain and were merely conclusory. Here, BCBSSC relied on the opinions of four board certified medical reviewers who made specific findings addressing established Plan Medical Necessity criteria using Plaintiff's own medical records and objective medical evidence. On the other hand, Plaintiff's treating physician made conclusory statements that did not address the Plan criteria, and were inconsistent with Plaintiff's own medical records and objective medical evidence. As a result, the Court finds that DuPerry is distinguished and has no application to the facts of this case.
The Court's review of the administrative record establishes that the Plan's decision to deny Plaintiff's claims resulted from a process that was deliberate and principled. There was substantial evidence in the administrative record indicating that Plaintiff failed to meet the required Medical Necessity Plan criteria. Therefore, the surgical procedure and durable medical equipment requested by Plaintiff was not in accordance with generally accepted standards of medical practice, and was not clinically appropriate, in terms of type, frequency, extent, site and duration, and was not considered effective for the patient's illness, injury or disease, and therefore was not Medically Necessary. BCBSSC reviewed all medical records submitted by Plaintiff and/or his providers. Multiple medical reviews were performed on Plaintiff's claim by board certified physicians including independent external specialists. BCBSSC applied unambiguous Plan terms and specifically approved, peer-reviewed criteria in reviewing Plaintiff's claims. Plaintiff and/or his providers were given ample opportunity to submit any evidence they desired to support Plaintiff's claims and his appeals. Plaintiff and/or his providers even availed themselves to a peer to peer call and an external medical review. At all times during the claim, Plaintiff was kept apprised of the status of the claim and written communications with Plaintiff fully informed Plaintiff of his ERISA rights. Accordingly, the Court finds that the Plan's claim determination was deliberate, principled and was not an abuse of discretion. See Donnell v. Metro. Life Ins. Co., 165 Fed. Appx. 288, 294-95 (4th Cir. 2006) (approving of decision making process that included review of all submitted medical evidence, measurement of claimant's vocational abilities, an independent medical evaluation, and timely notice of claim status); see Hensley v. IBM, 123 Fed. Appx. 534, 538 (4th Cir. 2004) (record demonstrated decision to terminate benefits resulted from a deliberate, principled reasoning process where administrator issued multiple requests for information from claimant's physicians, conducted several reviews of her medical records by independent consultants, and, on appeal, gave consideration to claimant's supplemental medical evidence); Tucci v. First Unum Life Ins. Co., 446 F.Supp.2d 473, 484-85 (D.S.C. 2006) (review process "deliberate and principled" where insurer obtained input from treating physicians, obtained multiple medical reviews of claimant's records, reviewed all medical records, offered claimant the opportunity to provide supplemental medical evidence, advised claimant of her rights, and kept claimant apprised of the status of her claim).
As was previously discussed, the Court holds that BCBSSC's interpretation was consistent with the terms of the Plan. The Court also finds that Plaintiff failed to submit any evidence that the BCBSSC's interpretation was inconsistent with any prior interpretations. Accordingly, this Booth factor weighs in Defendants' favor.
As was previously discussed, the Court holds that the Plan's claim determination was reasoned and principled.
The Court's review of the administrative record indicates that there were no procedural irregularities during the claim. Plaintiff was kept informed as to the status of his claim. The denial letters fully and/or substantially complied with the requirements of the ERISA claim regulations. Once the claim was initially denied, Plaintiff was given opportunities to appeal and supply BCBSSC with supporting documentation. Accordingly, the Court finds that the Plan fully complied with the procedural and substantive requirements of ERISA.
The Court finds that no party submitted any evidence of any external standard relevant to this case. Therefore, the Court finds that this Booth factor is not applicable to this case.
As this Court previously discussed in its holding concerning the applicable standard of review, the Court finds that while a potential structural conflict of interest existed, the safeguards mentioned above mitigated against giving the potential conflict any great weight.
The parties stipulated in the Joint Stipulation that Plaintiff's claim can be decided on the administrative record, and no party argued that evidence outside of the administrative record should be considered by the Court. Therefore, the Court finds that this Booth factor does not apply to this case.
After careful consideration of the relevant Memoranda In Support of Judgment, the administrative record and the Joint Stipulation, the Court determines that the Defendants engaged in a deliberate, principled reasoning process and that their decision was supported by substantial evidence that the services requested by Plaintiff were not Medically Necessary and/or were Experimental or Investigational under the terms of the Plan. Therefore, for the reasons set out herein, is hereby ordered that Defendants' Motions for Judgment are granted and that Plaintiff's Motion for Judgment is denied.
