September 6, 2018 Boston, Massachusetts. Where the United States District Court for the District of Massachusetts upheld the denial of ERISA health plan coverage for the time a plaintiff spent at a mental health residential treatment facility, the First Circuit Court of Appeals reversed. Doe v. Harvard Pilgrim Health Care, Inc., —F.3d.—, 2018 WL 4237288 (1st Cir. 2018). In the First Circuit appeal, Jonathan M. Feigenbaum on brief for United Policyholders and Health Law Advocates, Inc., amici curiae. Jane Doe was represented by attorneys Mala M. Rafik and Sarah E. Burns., both of Boston.
Doe v. HPHC Decision
Jane Doe’s insurer, Harvard Pilgrim Health Care (‘HPHC’), had concluded that a portion of the time Jane Doe, a college student, was receiving care at a psychiatric residential treatment facility was not medically necessary. Jane was insured under the health care benefits plan established by the employer of Doe’s parent. HPHC contended certain care was not medically necessary. After several unsuccessful administrative appeals, Doe sued HPHC under the Employee Retirement Income Security Act (‘ERISA’). 29 U.S.C. §§1001–1461. On de novo review, court agreed with HPHC’s determination that continued residential treatment was not medically necessary for Doe. The First Circuit disagreed with the District Court’s conclusion. “We conclude that the administrative record upon which the district court based its finding should have been supplemented. We therefore reverse in part, vacate in part, and remand for further proceedings. …” [Read more…]