United States District Court, N.D. Ohio, Eastern Division
OPINION AND ORDER
CHRISTOPHER A. BOYKO UNITED STATES DISTRICT JUDGE
matter is before the Court on Plaintiff's Complaint
seeking to reverse the decision of Defendant Cleveland Clinic
Employee Health Plan Total Care denying Plaintiff employee
health benefits in violation of the Employee Retirement
Income Security Act (“ERISA”) 29 U.S.C. §
1002 . For the following reasons, the Court affirms the
decision of the health plan.
to Plaintiff's Complaint, in the Spring of 2010,
Plaintiff Jason Springer, a physician in Utah, accepted a
physician position with the Cleveland Clinic in Ohio.
Plaintiff was to begin his employment with the Cleveland
Clinic on July 1, 2010. Plaintiff enrolled himself, his wife
and his son, J.S., in the Cleveland Clinic's health plan.
Under the terms of the Plan, it reads “as along as you
have enrolled in the health plan within 31 days of your start
date, your coverage is effective on the first day you
actively start to work.” (AR 15-1, pg. CCEHP
000011). Thus, according to Plaintiff, his family
were participant/beneficiaries under the Plan on July 1,
suffers from a number of serious health conditions that
require round-the-clock healthcare. When Plaintiff accepted
the Cleveland Clinic position, he arranged to have J.S
transported via air ambulance to the Cleveland Clinic.
J.S.'s primary care physician signed a Medical Letter of
Necessity explaining the need for such transport services.
Plaintiff's choice of air ambulance service, Angel Jet
Services, LLC (“Angel Jet”), attempted to obtain
precertification from Defendant for the transport from
Defendant's Plan Administrator Antares Management
Solutions, Inc. (“Antares”) but Antares was
unable to verify Plaintiff's family's enrollment at
the time service was provided.
7, 2010, J.S. was transported via air ambulance to Cleveland.
Shortly thereafter, Angel Jet submitted a bill to Antares for
$340, 100 for J.S.'s transport. On August 31, 2010, an
Antares representative informed Angel Jet the claim was
approved. However, on September 2, 2010, the claim was
subsequently denied for failure to obtain precertification.
provides its own air ambulance service via a third party
carrier. Based on this relationship, the Plan offers members
a steep discount on air ambulance services. On January 27,
2011, Defendant issued Angel Jet a check for 10 percent of
the billed charges. According to Defendant, this payment
reflected the amount the Plan's exclusive air transport
service would have charged for transporting J.S.
exhausted all administrative appeals of the denial of the
benefits owed under the Plan, Plaintiff appeals the denial of
the full amount of his Plan benefits.
to Defendant, Plaintiff lacks constitutional standing to
assert his ERISA claim because he does not allege that Angel
Jet has sought to recover its unreimbursed fees from
Plaintiff. Without this allegation, Defendant contends
Plaintiff has failed to allege an injury arising from the
Plan's 10 percent payment. Furthermore, the same issues
that formed the central dispute in Angel Jet apply
here -i.e.- whether it was arbitrary and capricious of the
Plan to deny coverage for non-emergency medical transport of
J. S. when Plaintiff failed to obtain preauthorization.
Because the transport of J. S. was not an emergency
situation, there was no necessity on the part of Plaintiff to
transport J. S. via air ambulance without first obtaining
first issue the Court must address is whether the Plan
confers upon the Plan Administrator the discretion to
determine eligibility and construe the terms of the Plan. In
determining the appropriate standard of review, the United
States Supreme Court held the “denial of benefits
challenged under § 1132(a)(1)(B) is to be reviewed under
a de novo standard unless the benefit plan gives the
administrator or fiduciary discretionary authority to
determine eligibility for benefits or to construe the terms
of the plan.” Firestone Tire & Rubber Co. v.
Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 956-57, 103
L.Ed. 2D 80 (1989) The Court applies the arbitrary and
capricious standard of review where a policy cloaks the plan
administrator with the discretionary authority to determine
eligibility and construe the terms of a policy. DeLisle
v. Sun Life Assurance Co. of Canada, 558 F.3d 440 (6th
Cir. 2009) (Citing Firestone Tire & Rubber Co. v.
Burch, 489 U.S. 101, 115 (1989)). The arbitrary and
capricious standard is the most deferential form of judicial
review. Admin. Comm. of Sea Ray Employees Stock Ownership
and Profit Sharing Plan v. Robinson, 164 F.3d 981, 989
(6th Cir. 1999). The administrator's decision should be
upheld if it is “the result of a deliberate, principled
reasoning process” and “supported by substantial
evidence.” Glenn v. Metro. Life Ins.
Co., 461 F.3d 660, 666 (6th Cir. 2006),
aff'd, 128 S.Ct. 2343 (2008). In other words,
“when it is possible to offer a reasoned explanation,
based on the evidence, for a particular outcome, that outcome
is not arbitrary or capricious.” Davis v. Kentucky
Finance Cos. Retirement Plan, 887 F.2d 689, 693 (6th
Cir.1989). “In applying the arbitrary and capricious
standard in ERISA actions, a court is limited to reviewing
the evidence contained within the administrative
record.” Kouns v. Hartford Life & Acc. Ins.
Co, 780 F.Supp.2d 578, 584-85 (N.D. Ohio 2011) citing
Wilkins v. Baptist Healthcare System, Inc., 150 F.3d
609, 615 (6th Cir.1998). “A court should utilize the
arbitrary and capricious standard even when a conflict of
interest exists.” Kouns, 780 F.Supp.2d at 584
citing Metro. Life Ins. Co. v. Glenn, 554 U.S. 105
(2008). “The Supreme Court has held that a conflict of
interest exists for ERISA purposes where the plan
administrator evaluates and pays benefit claims, even where
the administrator is an insurance company and not the
beneficiary's employer.” Kouns, 780
F.Supp.2d at 584 citing Glenn, 554 U.S. at 111, 128
S.Ct. 2343. Courts will weigh a potential conflict of
interest as a factor in determining whether the decision to
deny benefits was arbitrary and capricious. Glenn,
554 U.S. at 117, 128 S.Ct. 2343; Firestone, 489 U.S.
at 115, 109 S.Ct. 948. A possible conflict of interest due to
the administrator's dual role is “but one factor
among many that a reviewing judge must take into
account.” Glenn, 128 S.Ct. at 2351.
the Cleveland Clinic Employee Health Plan Total Care
expressly identifies Antares as its third party
administrator. The Plan reads:
Antares Management Solutions (Antares) functions as the
Administrator (TPA) for Cleveland Clinic Employee Health Plan
(EHP) Total Care. In this role, they are responsible for:
1. Member eligibility verification
2. Benefit coverage determinations 3. Processing claims and
4. Issuing statements of Explanation of Benefits (EOB)
5. Coordinating benefits if a member is covered by more than