Monte Hooper v. UnitedHealthcare Insurance
694 F. App'x 902
| 4th Cir. | 2017Background
- ERISA action where Hooper sues Michelin Plan, the Board, and UHC for additional reimbursement for Mrs. Hooper’s steroid knee injections; the Plan is self-funded and administered under an SPD; CPT codes submitted by the in-network surgeon classified injections as office surgery; UHC paid 100% for the office visit and 80% for the injections with a $65 copay for the visit; Hooper exhausted administrative remedies with UHC and Michelin Appeals Board which denied the claim; district court granted summary judgment for defendants; on appeal the court reviews for abuse of discretion under ERISA; the court considers whether the CPT-based classification was reasonable and whether extra-record evidence may be considered; the court affirms denial of additional coverage.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether CPT codes used to classify injections as office surgery were a reasonable basis under the Plan | Hooper argues CPT codes may not determine surgery status; codes were not explicitly incorporated into Plan terms | Michelin/UHC relied on CPT codes as industry standard for classification | No abuse; CPT-based classification reasonable |
| Whether information from the IBAAG webpage should have altered the classification | IBAAG would require 100% payment for injections | SPD does not incorporate IBAAG; injections context ambiguous but consistent with CPT-based interpretation | No error; IBAAG not part of Plan terms; even if imputed, not unreasonable |
| Whether the district court should have considered extra-record evidence under Booth eight-factor test | Hooper submitted additional evidence to show abuse of discretion | Evidence not before administrator and not known to Michelin; not within Booth factors | No; court did not abuse discretion or require consideration of late-record evidence |
Key Cases Cited
- Booth v. Wal–Mart Stores, Inc. Assocs. Health & Welfare Plan, 201 F.3d 335 (4th Cir. 2000) (eight Booth factors for abuse of discretion)
- Johnson v. Am. United Life Ins. Co., 716 F.3d 813 (4th Cir. 2013) (de novo review with discretionary review when appropriate)
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989) (establishes abuse-of-discretion framework for ERISA plans)
- United McGill Corp. v. Stinnett, 154 F.3d 168 (4th Cir. 1998) (reasonableness standard under abuse of discretion review)
- de Nobel v. Vitro Corp., 885 F.2d 1180 (4th Cir. 1989) (principled reasoning required; cannot substitute own interpretation)
- Helton v. AT&T Inc., 709 F.3d 343 (4th Cir. 2013) (exceptions allowing outside-record evidence in limited circumstances)
- U.S. Airways, Inc. v. McCutchen, 133 S. Ct. 1537 (2013) (context for interpreting plan terms and external standards)
- Harrison v. Wells Fargo Bank, N.A., 773 F.3d 15 (4th Cir. 2014) (practice cited regarding information not adequately supported)
- Newport News Shipbuilding & Dry Dock Co. v. Loxley, 934 F.2d 511 (4th Cir. 1991) (CPT is industry standard for reporting procedures)
- Apple Inc. v. Psystar Corp., 658 F.3d 1150 (9th Cir. 2011) (CPT as industry standard in coding)