South Carolina Lawyers Weekly
Where UnitedHealthcare failed to provide documents requested by a father who sought payments for services provided to his minor son on the basis the documents were HIPPA-protected, but some were not HIPPA protected, the father had a right to obtain plan-related documents and United never told him he had submitted a deficient HIPPA form, the plan administrator must undertake a full review of the claim.
Background
After health insurance payments for services provided to his minor son were denied, Kenneth Wilson filed a complaint challenging that determination under. The district court affirmed the plan administrator’s denial of coverage for the son’s treatment from Dec. 1, 2015, through May 15, 2016, concluding the plan administrator acted reasonably. In addition, the district court dismissed Wilson’s claims arising from treatment his son received from May 15, 2016, through his discharge on July 31, 2017, for failure to exhaust administrative remedies.
First dates of service
The first dates of service or DOS, encompasses services the Change Academy at Lake of the Ozarks or CALO, provided from Dec. 1, 2015, through May 15, 2016. For this period, having reviewed the record and the admission guidance, the court concludes that United acted within its discretion to deny J.W.’s claims.
The three independent reviewers separately arrived at the same conclusion: the 24-hour residential setting of services provided at CALO was no longer needed by the beginning of—and throughout—the first DOS. That determination is consistent with the criteria United established pursuant to the plan, which set out that coverage can be denied for not being medically necessary when care could have occurred at a less intensive setting.
Second and third DOS
Wilson asserts he was excused from exhausting the administrative remedies for the services provided during the second DOS (July 16-31, 2016; Aug. 1-15, 2016 and Nov. 1-30, 2016) and the third DOS (all other dates of services CALO provided from May 15, 2016, through J.W.’s discharge) because he initiated an appeal and requested copies of documents, but United failed to respond to either, thwarting the plan’s internal review process and making exhaustion futile.
Wilson’s counsel sent letters on Jan. 26, 2017, and Feb. 24, 2017, addressing the claims for the entire second DOS. The court concludes that it’s appropriate to consider claims for services denied before the date of the January 26 letter as part of the analysis of the 2017 letters’ substance, but that claims for services denied after that date do not reasonably fall within its scope. The court will adopt the phrase “modified third DOS” to refer to the subset of third DOS claims affected by the court’s analysis of the 2017 letters’ requests. To reiterate, the modified third DOS consists of any claims that are not part of the first DOS or second DOS and that United had denied coverage for as of Jan. 26, 2017. The analysis that follows concerning the 2017 letters relates solely to the second DOS and the modified third DOS.
The 2017 letters requested that United provide certain materials to Wilson’s counsel. United did not provide any of the requested materials or respond to the letters in any fashion, although Wilson had the right to request and receive copies of the requested documents, which United would ordinarily be obligated to provide. United insists that it had no obligation to produce any materials because they are all protected by HIPAA and Wilson’s HIPAA authorization form was fatally defective.
However, it is clear that some of the requested materials should have been disclosed because they do not constitute and would not lead to J.W.’s “individually identifiable health information” and thus would not require a HIPAA-compliant authorization form before being provided to Wilson’s counsel. Further, it’s undisputed that the 2017 letters plainly identified Wilson as a plan participant, such that he had a right under the plan and ERISA to obtain copies of certain generally applicable plan-related documents upon request (or upon his authorized representative’s request).
Finally, ERISA and the plan obligated United to respond to the request by notifying Wilson’s counsel of the existence of the potentially defective HIPAA authorization form attached to the 2017 letters. Given this, the best course is to remand for the plan administrator to undertake a full and fair review in the first instance. As for the claims that United denied after Jan. 26, 2017, however, Wilson has failed to show that he exhausted his administrative remedies or that the futility exception should apply.
Affirmed in part, vacated in part and remanded with instructions.
Wilson v. UnitedHealthcare Insurance Company (Lawyers Weekly No. 001-040-22, 41 pp.) (G. Steven Agee, J.) Case No. 20-2044. Feb. 24, 2022. From D.S.C. at Charleston (David C. Norton, J.) M. Leila Louzri for Appellant. Cavender Crosby Kimble for Appellee. 4th Cir.
