974 F.3d 69
1st Cir.2020Background
- Jane Doe was admitted to the Austen Riggs Center (residential mental‑health facility) on January 17, 2013; Harvard Pilgrim initially authorized brief coverage but denied continued coverage as of February 6–13, 2013 after internal and OPP reviews.
- The disputed coverage period is February 13, 2013 through June 18, 2013; Doe remained at Riggs during that period, was transferred to inpatient care on June 18, then readmitted to Riggs June 24 (for which Harvard Pilgrim later authorized coverage).
- Doe sued under ERISA § 502(a)(1)(B) seeking de novo review of the denial for the February–June period; the district court initially limited the record to the administrative materials as of March 12, 2013 and granted summary judgment to Harvard Pilgrim.
- On first appeal (Doe I) the First Circuit vacated and directed the district court to include materials generated by the insurer’s supplemental review and certain interim documents, and explained that factual findings on remand would be reviewed only for clear error.
- On remand the district court again granted summary judgment to Harvard Pilgrim, concluding Doe had not met the plan’s "medically necessary" criteria as of February 13, and denied Doe fees for her interim appellate success; the First Circuit affirms both rulings.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Doe met the plan's "medically necessary" criteria for residential care as of Feb. 13, 2013 | Doe: met criteria 1 and 2 (needed 24‑hour structure; risk of deterioration at lower care) | Harvard Pilgrim: did not meet criteria; experts found no need for 24‑hour supervision/structure | Affirmed — district court did not clearly err; Doe had not shown medical necessity as of Feb. 13 |
| Whether experts improperly applied a stricter standard (requiring 24‑hour nursing care) contrary to Guidelines' "24‑hour structure" language | Doe: experts conflated "24‑hour nursing care" with eligibility, invalidating denial | Harvard Pilgrim: references to 24‑hour care were contextual/availability‑based and not a misapplied standard | Affirmed — court reasonably read reports; no clear error in relying on them |
| Proper scope of the record and need for live testimony / expanded evidence on remand | Doe: sought evidentiary hearing, live testimony, or a broader supplemental record beyond what was before the administrator | Harvard Pilgrim: record should be limited to materials submitted to administrator absent special circumstances | Affirmed — district court correctly limited review to the administrative record and declined live testimony |
| Whether Doe is entitled to attorneys' fees for her success on the prior appeal (Doe I) | Doe: remand victory (clarifying the record and review standard) warrants fees under Hardt and Gross | Harvard Pilgrim: even if eligible, Cottrill factors do not support an award; insurer's conduct not sufficiently culpable | Affirmed — district court did not abuse discretion in denying fees after applying Cottrill factors |
Key Cases Cited
- Doe v. Harvard Pilgrim Health Care, Inc., 904 F.3d 1 (1st Cir. 2018) (prior panel opinion directing supplementation of the administrative record and explaining appellate review standard)
- Stephanie C. v. Blue Cross Blue Shield of Mass. HMO Blue, Inc., 813 F.3d 420 (1st Cir. 2016) (ERISA summary‑judgment practice as vehicle for administrative‑record decision)
- Stephanie C. v. Blue Cross Blue Shield of Mass. HMO Blue, Inc., 852 F.3d 105 (1st Cir. 2017) (district court may weigh facts de novo when administrator lacks discretionary authority)
- Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510 (1st Cir. 2005) (district court review of administrator's decision should generally be limited to the administrative record; live testimony not required)
- Liston v. UNUM Corp. Officer Severance Plan, 330 F.3d 19 (1st Cir. 2003) (strong presumption that review is confined to administrator's record absent special circumstances)
- Hardt v. Reliance Standard Life Ins. Co., 560 U.S. 242 (2010) (attorney’s‑fee eligibility under § 1132(g)(1) requires "some degree of success on the merits")
- Gross v. Sun Life Assurance Co. of Can., 763 F.3d 73 (1st Cir. 2014) (court‑ordered remand to administrator can, in some circumstances, support fee eligibility)
- Cottrill v. Sparrow, Johnson & Ursillo, Inc., 100 F.3d 220 (1st Cir. 1996) (five‑factor framework for discretionary fee awards under ERISA)
- Doe v. Standard Ins. Co., 852 F.3d 118 (1st Cir. 2017) (summary judgment in ERISA context as mechanism to decide claims on the administrative record)