Harvard Pilgrim Wins Appeal Over $800-Per-Day Mental Health Care

Harvard Pilgrim Health Care Inc. defeated a college student’s lawsuit seeking coverage for four months of treatment at an $800-per-day mental health facility when the First Circuit said Wednesday a reasonable reading of expert reports backed the coverage denial.

The student, referred to as Jane Doe, said the federal judge who ruled against her was wrong to rely on the reports she said were incorrectly premised on the idea that coverage was available only if her symptoms required 24-hour care.

The U.S. Court of Appeals for the First Circuit disagreed, saying it was “hardly error” for the experts to note that she didn’t require round-the-clock care, or for the district court to rely on this in its ruling.

Doe also argued she should have been awarded attorneys’ fees for litigating early stages of the lawsuit, which led to a 2018 decision from the First Circuit that revived her case.

Doe cited the court’s 2014 ruling in Gross v. Sun Life Assurance Co. of Canada.

The court held there that a plan participant seeking benefits under the Employee Retirement Income Security Act may be eligible for fees after a court remands a case to a plan administrator for more analysis.

The First Circuit said, however, it “need not decide” whether Doe’s earlier victory made her eligible for attorneys’ fees.

The district properly held a fee award wasn’t warranted in this case, even assuming Doe was eligible for one under the rule set forth in Gross, the First Circuit said.

Judge William J. Kayatta Jr. wrote the decision. Judges Bruce M. Selya and Juan R. Torruella joined.

Doe was represented by Rosenfeld & Rafik PC. Harvard Pilgrim was represented by Anderson & Kreiger LLP.

The case is Doe v. Harvard Pilgrim Health Care, Inc., 1st Cir., No. 19-1879, 9/9/20.