Filed: Oct. 15, 2015
Latest Update: Mar. 02, 2020
Summary: 14-3931 Tansey v. Anthem Health Plan, Inc. UNITED STATES COURT OF APPEALS FOR THE SECOND CIRCUIT SUMMARY ORDER RULINGS BY SUMMARY ORDER DO NOT HAVE PRECEDENTIAL EFFECT. CITATION TO A SUMMARY ORDER FILED ON OR AFTER JANUARY 1, 2007, IS PERMITTED AND IS GOVERNED BY FEDERAL RULE OF APPELLATE PROCEDURE 32.1 AND THIS COURT’S LOCAL RULE 32.1.1. WHEN CITING A SUMMARY ORDER IN A DOCUMENT FILED WITH THIS COURT, A PARTY MUST CITE EITHER THE FEDERAL APPENDIX OR AN ELECTRONIC DATABASE (WITH THE NOTATION “SU
Summary: 14-3931 Tansey v. Anthem Health Plan, Inc. UNITED STATES COURT OF APPEALS FOR THE SECOND CIRCUIT SUMMARY ORDER RULINGS BY SUMMARY ORDER DO NOT HAVE PRECEDENTIAL EFFECT. CITATION TO A SUMMARY ORDER FILED ON OR AFTER JANUARY 1, 2007, IS PERMITTED AND IS GOVERNED BY FEDERAL RULE OF APPELLATE PROCEDURE 32.1 AND THIS COURT’S LOCAL RULE 32.1.1. WHEN CITING A SUMMARY ORDER IN A DOCUMENT FILED WITH THIS COURT, A PARTY MUST CITE EITHER THE FEDERAL APPENDIX OR AN ELECTRONIC DATABASE (WITH THE NOTATION “SUM..
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14-3931
Tansey v. Anthem Health Plan, Inc.
UNITED STATES COURT OF APPEALS
FOR THE SECOND CIRCUIT
SUMMARY ORDER
RULINGS BY SUMMARY ORDER DO NOT HAVE PRECEDENTIAL EFFECT. CITATION TO A SUMMARY ORDER FILED
ON OR AFTER JANUARY 1, 2007, IS PERMITTED AND IS GOVERNED BY FEDERAL RULE OF APPELLATE
PROCEDURE 32.1 AND THIS COURT’S LOCAL RULE 32.1.1. WHEN CITING A SUMMARY ORDER IN A
DOCUMENT FILED WITH THIS COURT, A PARTY MUST CITE EITHER THE FEDERAL APPENDIX OR AN
ELECTRONIC DATABASE (WITH THE NOTATION “SUMMARY ORDER”). A PARTY CITING A SUMMARY ORDER MUST
SERVE A COPY OF IT ON ANY PARTY NOT REPRESENTED BY COUNSEL.
1 At a stated term of the United States Court of Appeals
2 for the Second Circuit, held at the Thurgood Marshall United
3 States Courthouse, 40 Foley Square, in the City of New York,
4 on the 15th day of October, two thousand fifteen.
5
6 PRESENT: DENNIS JACOBS,
7 RAYMOND J. LOHIER, JR.,
8 Circuit Judges,
9 GEOFFREY W. CRAWFORD,*
10 District Judge.
11
12 - - - - - - - - - - - - - - - - - - - -X
13 NEIL TANSEY and CATHERINE TANSEY,
14 Plaintiffs-Appellants,
15
16 -v.- 14-3931
17
18 ANTHEM HEALTH PLANS, INC. d/b/a ANTHEM
19 BLUE CROSS AND BLUE SHIELD and ANTHEM
20 UM SERVICES, INC.,
21 Defendants-Appellees.
22 - - - - - - - - - - - - - - - - - - - -X
23
*
The Honorable Geoffrey W. Crawford, of the United
States District Court for the District of Vermont, sitting
by designation.
1
1 FOR APPELLANTS: PHILIP E. MURRAY, JR., Murray,
2 Kelly & Bertrand, P.C., Woburn,
3 Massachusetts.
4
5 FOR APPELLEES: MICHAEL G. DURHAM, MATTHEW H.
6 GEELAN, Donahue, Durham &
7 Noonan, P.C., Guilford,
8 Connecticut.
9
10 Appeal from a judgment of the United States District
11 Court for the District of Connecticut (Covello, J.).
12
13 UPON DUE CONSIDERATION, IT IS HEREBY ORDERED, ADJUDGED
14 AND DECREED that the judgment of the district court be
15 AFFIRMED.
16
17 Plaintiffs Catherine Tansey and her father appeal from
18 the judgment of the United States District Court for the
19 District of Connecticut (Covello, J.), granting judgment on
20 the administrative record in favor of Anthem Health Plans,
21 Inc. d/b/a Anthem Blue Cross and Blue Shield, and Anthem UM
22 Services, Inc. (collectively, “Anthem”). We assume the
23 parties’ familiarity with the underlying facts, the
24 procedural history, and the issues presented for review.
25
26 1. We review the district court’s grant of judgment
27 on the administrative record de novo and apply the same
28 standard as the district court. Hobson v. Metro. Life Ins.
29 Co., 574 F.3d 75, 82 (2d Cir. 2009). Anthem denied health
30 care benefits, under an ERISA1 benefit plan, for Ms.
31 Tansey’s residential treatment in a substance abuse
32 facility. The denial must be upheld unless it was arbitrary
33 and capricious--that is, unless it was “without reason,
34 unsupported by substantial evidence or erroneous as a matter
35 of law.” Pagan v. NYNEX Pension Plan,
52 F.3d 438, 442 (2d
36 Cir. 1995) (internal quotation marks and citation omitted).
37 “Substantial evidence . . . is such evidence that a
38 reasonable mind might accept as adequate to support the
39 conclusion reached by the decisionmaker and requires more
40 than a scintilla but less than a preponderance.” Miller v.
41 United Welfare Fund,
72 F.3d 1066, 1072 (2d Cir. 1995)
42 (internal quotation marks, alterations, and citation
43 omitted).
1
The Employee Retirement Income Security Act of 1974,
29 U.S.C. § 1132.
2
1
2 2. Ms. Tansey was covered under the group health
3 benefit plan issued to her father’s employer. She was
4 eligible for benefits for covered services only for
5 “Medically Necessary Care,” defined as “health care services
6 . . . that are,” inter alia, “[c]linically appropriate, in
7 terms of type, frequency, extent, site and duration and
8 considered effective for the patient’s illness, injury or
9 disease; and . . . not more costly than an alternative
10 service or sequence of services at least as likely to
11 produce equivalent therapeutic or diagnostic results as to
12 the diagnosis or treatment of that patient’s illness, injury
13 or disease.” Benefits for “confinement in a Residential
14 Treatment Facility” in connection with mental health and
15 substance abuse services are provided only when “the insured
16 has a Medically Necessary, serious mental or nervous
17 condition that . . . cannot appropriately, safely or
18 effectively be treated in an acute care, partial
19 hospitalization, intensive outpatient or outpatient
20 setting.”
21
22 3. Anthem denied the claim on the grounds that it was
23 not medically necessary. This determination is not
24 irrational or legally erroneous, and is supported by
25 substantial evidence from which Anthem could have determined
26 that residential treatment was not clinically appropriate,
27 and/or that recovery could have occurred as effectively and
28 safely at a lower level of care (including partial
29 hospitalization or intensive outpatient treatment).
30
31 A. Prior to Ms. Tansey’s admission to Fulshear Ranch
32 Academy (“Fulshear”), the only treatment she had attempted
33 in her home environment had included 10 psychotherapy
34 sessions and an 8-day afterschool program in April or May of
35 2009, which she described as being “about ‘normal teenage
36 stuff.’” Immediately prior to her admission to Fulshear,
37 Ms. Tansey had participated in a 2-month wilderness program.
38 She had never received partial hospitalization or intensive
39 outpatient treatment in her home environment.
40
41 B. The therapist at the wilderness program stated
42 that Ms. Tansey had “addressed all of her various treatment
43 goals.” At discharge, her mood was “fairly stable.” A
44 psychological evaluation conducted during the program
45 indicated that symptoms of depression and anxiety were not
46 sufficient in number or intensity to amount to Major
3
1 Depressive or Anxiety Disorder. Nor did Ms. Tansey meet the
2 full criteria for either anorexia or bulimia.
3
4 The Fulshear admission application indicated that Ms.
5 Tansey had not used drugs or alcohol since the start of the
6 wilderness program. An initial assessment conducted upon
7 admission indicated that she reported no significant medical
8 or mental health issues. Ms. Tansey scored a “high
9 probability” of substance abuse disorder, although the
10 assessment noted it “likely that she could have
11 ‘embellished’ on some of the scores . . . in order to make
12 sure she is seen as having an alcohol/drug problem.”
13
14 C. Four physicians opined that residential
15 rehabilitation treatment was not medically necessary--
16 including one outside consultant and one consultant retained
17 by an independent, impartial review organization, with no
18 connection to Anthem. Plaintiffs object to the opinions as
19 unreasoned or irrational. They contend that the initial
20 review and second-level appeal physicians’ opinions relied
21 on “erroneous facts” because, inter alia, they referenced
22 marijuana as Ms. Tansey’s drug-of-choice, and noted that she
23 reported bulimic symptoms three years prior but not at that
24 time. There is record support for the facts referenced in
25 the physicians’ opinions. Even if (as plaintiffs argue) the
26 physicians who provided the initial review and first-level
27 appeal opinions incorrectly considered medical necessity
28 pursuant to Anthem’s 2010 Adult Substance Abuse Subacute/RTC
29 Rehabilitation criteria, those who performed the second-
30 level and external reviews indisputably were provided with
31 and applied the four criteria that Plaintiffs argue might
32 apply. The treating therapists and physicians offered
33 contrary opinions, but in an ERISA benefits dispute, no
34 “special weight” is given to the opinions of treating
35 sources. Hobson, 574 F.3d at 90 (“[A plan administrator] is
36 not required to accord the opinions of a claimant’s treating
37 physicians ‘special weight,’ especially in light of contrary
38 independent physician reports.” (quoting Black & Decker
39 Disability Plan v. Nord,
538 U.S. 822, 834 (2003))).
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1 For the foregoing reasons, and finding no merit in the
2 Tanseys’ other arguments, we hereby AFFIRM the judgment of
3 the district court.
4
5 FOR THE COURT:
6 CATHERINE O’HAGAN WOLFE, CLERK
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