United States District Court, N.D. Illinois, Eastern Division
DOMINIC W. on behalf of SOFIA W., Plaintiff,
THE NORTHERN TRUST COMPANY EMPLOYEE WELFARE BENEFIT PLAN and HEALTH CARE SERVICE CORPORATION, d/b/a BLUE CROSS AND BLUE SHIELD OF ILLINOIS, Defendants.
MEMORANDUM OPINION AND ORDER
Matthew F. Kennelly, United States District Judge.
W. is an employee of the Northern Trust Company. On behalf of
his minor daughter, Sofia W., he has sued the Northern Trust
Company Employee Welfare Benefit Plan and the plan's
administrator, Health Care Service Corporation, which does
business as Blue Cross and Blue Shield of Illinois. Dominic
alleges that the plan and Blue Cross improperly refused to
cover residential treatment for Sofia's mental health
issues after Blue Cross erroneously concluded that
residential treatment was no longer medically necessary. Both
sides have moved for summary judgment.
following facts are drawn from the claim file and are
undisputed except where otherwise noted.
Coverage of residential treatment under the employee benefit
is a beneficiary of her father's employer-provided health
insurance, the Northern Trust Employee Benefit Plan. The plan
is governed by the Employee Retirement Income Security Act
(ERISA) and is administered by Blue Cross.
different versions of the plan were in effect in 2016 and
2017, in both years the plan covered care in residential
treatment facilities so long residential treatment was
"medically necessary." In 2016, the plan defined
"medically necessary" to mean that the treatment
be ordered by a physician; be consistent with the symptoms,
diagnosis and treatment of your illness or injury; be
recognized by the medical community as the appropriate and
acceptable course of treatment; be given to you as an
inpatient only when services cannot be safely be provided as
an outpatient; not be provided solely for the convenience of
your physician, hospital, other provider or you; not be
educational or investigational; and not be provided primarily
2016 Sourcebook, dkt. no. 87-18, at PLAN000106. In 2017, a
"medically necessary" service was one that was
"required, in the reasonable medical judgment of the
Claim Administrator, for the treatment or management of a
medical symptom or condition." 2017 Benefit Booklet,
dkt. no. 87-18, at PLAN000443. In addition, the service must
have been "the most efficient and economical service
which [could] safely be provided." Id. The
parties agree that at all relevant times the plan gave the
administrator discretion to determine what treatments were
Sofia's medical history
was adopted as an infant. As a young child, she began
exhibiting behavioral problems, including emotional
instability, severe temper tantrums, and defiance. At the age
of 10, she started seeing a child therapist. Her
pediatrician, Dr. Nancy Horlick, also recommended that she
visit a child psychiatrist, Dr. Houshang Aminian. Dr. Aminian
prescribed Abilify, an antipsychotic and antidepressant
medication. In October 2014, Sofia began seeing a second
psychiatrist, Dr. Linda Kalivas. Dr. Kalivas diagnosed Sofia
with disruptive mood dysregulation disorder and adjusted the
prescribed dosage of Abilify.
treatment did not prevent Sofia's condition from
deteriorating. By March 2016, twelve-year-old Sofia's
behavior was increasingly disruptive and dangerous. She cried
uncontrollably at home and at school, refused to take her
medication, entered periods of extreme rage during which she
would scream at the top of her lungs, and expressed suicidal
thoughts. Her emotional outbursts reached an apex when she
swung a hammer at her mother's head. Soon thereafter,
Sofia told her mother that she planned to kill her in her
Admission to residential treatment
March 29, 2016, the day after Sofia threatened to kill her
mother, her parents brought her to Falcon Ridge Ranch, a
residential treatment center in Utah for adolescent girls. On
April 7, she underwent an initial psychiatric evaluation with
Dr. Randall Draper. Dr. Draper found that Sofia suffered from
disruptive mood dysregulation disorder, reactive attachment
disorder, and a parent-child relational problem. He wrote in
his evaluation that she required "treatment in a setting
away from her home, where the specific and focused
dysfunctional interaction with her mother appears to be the
main issue." Dr. Draper Evaluation, dkt. no. 87-1, at
BCBSIL_0000243. Dr. Draper further explained that
"[t]reatment in a less restrictive environment, such as
participation in outpatient treatment, is unlikely to be
successful, since it would entail living at home and
uninterrupted antipathetic interactions with her
mother." Id. On this basis, Dr. Draper
concluded that Sofia "requires a residential level of
care." Id. at BCBSIL_0000224.
April 13, 2016, Falcon Ridge therapist Amanda Nelson
described Sofia's condition in a therapy progress note.
See Progress Note of Apr. 13, 2016, dkt. no. 87- 1,
at BCBSIL_0000708. Among other observations, Nelson noted
that Sofia denied "suicidal or harm-ideation" but
wrote that she showed "a pattern of oppositional and
defiant behavior." Id. In a progress note the
following week, Nelson remarked, "Parents are supportive
of the therapeutic process." Progress Note of Apr. 18,
2016, dkt. no. 87-1, at BCBSIL_0000702.
Initial coverage decisions and subsequent residential
April 2016, Sofia's father Dominic submitted to Blue
Cross a timely claim for coverage of Sofia's residential
treatment at Falcon Ridge. Blue Cross initially approved the
request on April 14, relying on the opinion of one of its
consulting psychiatrists, Dr. Rakesh Chadalavada. Dr.
Chadalavada spoke with a Falcon Ridge clinician whom the
medical records identify only as "Terri G." Dr.
Chadalavada found that Sofia met the criteria for residential
treatment under the Milliman Care Guidelines, the treatment
standards Blue Cross uses to determine whether a particular
health care service is medically appropriate. He cited
Sofia's history "of extreme aggression at home"
as a basis for approving residential treatment and noted that
although she was "not showing any behaviors that she
exhibited with the family, . . . she has not [been] in much
contact with the family." Dr. Chadalavada Review, dkt.
no. 87-7, at BCBSIL_0005924. He also noted the apparent
absence of suicidal or homicidal ideation.
weeks later, on April 28, 2016, Blue Cross reversed its
coverage decision, stating that Sofia no longer met the
Milliman Care Guidelines for mental health residential
treatment. Specifically, Blue Cross gave the following
reasons for denying ongoing coverage:
You were not reported as being an imminent danger to self or
others. There was no evidence of inability to adequately care
for yourself with functioning in multiple sphere areas. You
were not reported as being aggressive or threatening. There
was no report of medical instability. There was no report of
psychosis or mania. From the clinical evidence, you can be
safely treated in a less restrictive setting such as MENTAL
HEALTH PARTIAL HOSPITAL/DAY TREATMENT (PHP).
Decision of Apr. 28, 2016, dkt. no. 87-1, at BCBSIL_0000314.
Blue Cross determined that the last day of medically
necessary residential treatment was April 27.
Cross based its decision to terminate coverage on the opinion
of consulting psychiatrist Dr. Aftab Qadir. Dr. Qadir did not
evaluate Sofia, but he spoke with Terri G., the Falcon Ridge
clinician. Dr. Qadir stated that he also reviewed
"[e]xisting clinical notes," Dr. Qadir Review, dkt.
no. 87-3, at BCBSIL_0002301, though the plaintiff disputes
that claim. It is undisputed, however, that at most Dr. Qadir
reviewed clinical notes dating back to Sofia's admission
to Falcon Ridge and did not base his opinion on any other
written opinion, Dr. Qadir noted that Sofia was "making
progressive improvements" and "opening up,"
and he reported that her "[r]ecent family session was
pleasant." Id. He also wrote that Sofia
"did not express her [homicidal ideation] toward
parents" and noted that her sleep had improved.
Id. Dr. Qadir concluded that she did not appear to
pose a risk to herself or others, she was medically stable,
she evinced no psychosis or mania, and no aggressive,
threatening, or violent behavior had been reported.
Ongoing residential treatment and self-harming
continued to receive residential treatment at Falcon Ridge
despite Blue Cross's determination that it was not
medically necessary for her to remain there. On May 2, 2016
psychologist Dylan Matsumori, Ph.D., wrote a report based on
two psychological evaluations of Sofia he conducted in April.
In stating his conclusions about the appropriate treatment
plan, Dr. Matsumori wrote,
It is recommended that Sofia continue in a multifaceted
residential treatment program. The program needs to include
individual, group and family counseling, as well as
academics and a behaviorally based structure. This will allow
her to have the stability and safety necessary to reflect
upon, understand and process her past behaviors, thought and
emotions while identifying her sense of self and
Matsumori Evaluation, dkt. no. 87-1, at BCBSIL0000577. Dr.
Matsumori also found that Sofia struggled to "face her
shortcomings frankly," explaining, "Care must be
taken in this regard not to be deceived by her superficial
compliance with these efforts." Id.
and June 2016, Sofia continued to have difficulties with
behavior management, anxiety, depression, and low self-image.
Her therapy progress reports reflect, however, that she
denied harming herself or experiencing suicidal ideation.
Reports of her physical health status in July and August also
indicate that she had not engaged in self-harming behaviors.
Sofia's psychological symptoms did not fully abate, and
indeed, in the autumn of 2016 they appear to have to worsened
considerably. By October 3, 2016, one therapist observed,
"Sofia shows increasing oppositional behavior and poor
mood. She shows a loss of focus and investment in her
treatment program." Clinical Report of Oct. 3, 2016,
dkt. no. 87-1, at BCBSIL_0000481. From September through
December 2016, Sofia was placed on suicide watch on five
occasions. On September 28, Amanda Nelson, Sofia's
therapist at Falcon Ridge, noted that she had been on
self-harm watch but that she measured low for suicide risk.
On October 11, Nelson wrote that Sofia had again been placed
on self-harm watch after making suicidal statements but
continued to deny having suicidal thoughts. Nelson also