Defendant's Attorney: Russell S. Buhite

Description: Eugene, Oregon employment law lawyer represented the Plaintiff who sued the Defendant on a wrongful denial of E.R.I.S.A. employee benefits.

This case, alleging claims under the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001 et seq., comes before the Court on cross-motions filed by Defendant PacificSource Health Plans (“PacificSource”), ECF No. 38; by Defendants Legacy Heath and Legacy Health Plan No. 504 (collectively, “Legacy”), ECF No. 40; and by Plaintiff Riley Boyle, ECF No. 41; and on Plaintiff's Motion to Strike the Declaration of Tammi Mizer, ECF No. 48. Plaintiff Riley Boyle seeks reimbursement for amounts she paid for out-of-network care. For the reasons set forth below, Defendants' Motions are DENIED and Plaintiff's Motions are GRANTED.

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Defendant PacificSource Health Plans (“PacificSource”) is the third-party administrator responsible for administering claims under the Plan. Legacy_00086-87. PacificSource provides administrative services for Plan participants including enrollment assistance, processing of medical claims, customer service, and recordkeeping. Legacy delegates responsibility for preliminary claim determination authority to PacificSource, which involves review of medical claims and application of Plan terms. PacificSource does not pay out benefits under the Plan. Benefits are paid exclusively by Legacy.

Plaintiff Riley Boyle is the daughter of Josie Boyle (“Mrs. Boyle”). Mrs. Boyle is an employee of Legacy and a participant in the Plan. At all material times, Plaintiff was a dependent of Mrs. Boyle and a participant in the Plan. At all material times, both Plaintiff and Mrs. Boyle resided in the State of Oregon. During much of the relevant time, Plaintiff was a minor and so Mrs. Boyle interacted with PacificSource on Plaintiff's behalf concerning coverage under the Plan.

II. The Plan

The Plan provides that “[t]he Benefits Plan and all Component Plans . . . shall be administered by an Administrative Committee of one or more person appointed by the chief executive officer of Legacy Heath, who may delegate that function.” Legacy_000165. “The Committee shall interpret the Benefits Plan, decide any questions about the rights of participants and their beneficiaries and in general administer the Plan.” Id. “Any decision by the Committee shall be final and bind all parties,” and “[t]he Committee shall have absolute discretion to carry out its responsibilities under this section.” Id.

“Claims and appeals of denied claims for benefits under uninsured Component Plans shall be governed by procedures established by the Committee and subject to the Committee's discretion within the requirements of applicable law and regulations.” Legacy_000166. “Claims and appeals of denied claims for benefits under fully insured Component Plans shall be administered in accordance with the terms of the applicable insurance contract.” Id.

The “Exclusive Provider Organization” (“EPO”) for the Plan is referred to as “Legacy+ Network” and is selected by Legacy and “maintained by PacificSource.” Legacy_000048. “Legacy+ Network participating physicians and providers are physicians, hospitals, health care professionals and facilities that contract to provide health care services to members.” Id. Physicians, health care professionals, hospitals, and facilities that are not part of the Legacy+ Network are “out-of-network” providers. Id.

The Medical Plan covers eligible services from Legacy+ Network facilities and providers with limited coverage outside of the Legacy+ Network. Legacy_000029. Out-of-network coverage is limited to (1) emergency and urgent care services for non-routine care; (2) “[c]overed services not available within the Legacy+ Network when pre-approved by PacificSource;” and (3) covered serviced received from licensed chiropractor or acupuncturist. Id.

“PacificSource reviews requests for out-of-network exceptions,” and if a participant or their provider believes a covered service is not available within the Legacy+ Network, the Plan directs them to contact PacificSource at a specified telephone number. Legacy_000030. Medical services that are not “medically necessary” are not covered. Id. However:

If PacificSource determined a requested covered service is medically necessary and not available from a Legacy+ Network provider or facility, the service is paid at a minimum of 80 percent and subject to the out-of-pocket maximum.

If PacificSource does not approve an out-of-network exception, the service is not covered and your costs are not included in the out-of-pocket maximum.

Legacy_000030.

The Plan provides 80% coverage for inpatient facility services for mental health treatment for Legacy+ Network providers and 0% for out-of-network providers. Legacy_000034.

The Plan also provides for pre-service and post-service claim procedures as follows:

If a claim is for a non-urgent benefit requiring advance approval or pre-certification, the claim administrator notifies the claimant of its decision, adverse or not, within a reasonable time appropriate to the medical circumstances, but not later than 15 days after the claim administrator received the claim, unless it contains insufficient information to base a decision or an extension is required for other reasons beyond the plan's control. In that case, the claim administrator may extend the time once for another period of up to 15 days.

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The claim administrator provides the claimant with written or electronic notice of any adverse determination, including: specific reason or reasons for the determination; reference to specific plan provisions on

which the determination is based; description of any additional material or information necessary for the claimant to perfect the claim and explanation of why it is necessary; description of the review procedure and applicable time limits; statement of the claimant's right to bring a legal action under ERISA following any adverse determination on review.

Legacy_000089.

Outcome: Defendant PacificSource Health Plans' Motion for Summary Judgment, ECF No. 38, is DENIED. Defendants Legacy Heath and Legacy Health Plan No. 504 (“Legacy”)'s Motion for Summary Judgment, ECF No. 40, is DENIED. Plaintiff Riley Boyle's Motion for Judgment, ECF No. 41, is GRANTED. Plaintiff's Motion to Strike the Declaration of Tammi Mizer, ECF No. 48, is GRANTED. Final judgment shall be entered accordingly.

Plaintiff's Experts:

Defendant's Experts:

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