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Brunelle v. Mid-America Associates, Inc.

United States District Court, E.D. Michigan, Southern Division

August 21, 2017

Dale Brunelle, Plaintiff,
v.
Mid-America Associates, Inc., and Liberty Union Life Assurance Company, Defendants.

          Elizabeth A. Stafford, Mag. Judge.

         OPINION AND ORDER GRANTING IN PART AND DENYING IN PART WITHOUT PREJUDICE PLAINTIFF'S MOTION FOR JUDGMENT ON THE ADMINISTRATIVE RECORD [19] AND DENYING WITHOUT PREJUDICE DEFENDANTS' MOTION FOR JUDGMENT ON THE ADMINISTRATIVE RECORD [21]

          JUDITH E. LEVY, UNITED STATES DISTRICT JUDGE.

         This case involves plaintiff Dale Brunelle's claim for benefits allegedly owed to him by defendants, pursuant to the terms of his ERISA benefit plan. Plaintiff and defendants have filed motions for judgment on the administrative record. (Dkts. 19, 21.)

         For the reasons set forth below, plaintiff's motion is granted in part and denied in part without prejudice, and defendants' motion is denied without prejudice.

         I. Background

         Plaintiff Dale Brunelle is an employee of Smith Construction Company, and is enrolled in an employee welfare benefit plan governed by ERISA, 29 U.S.C. § 1002 et seq. The plan went into effect on June 1, 2014. (Dkt. 15 at 372.) Defendants are insurance companies that “serve as the benefit administrators and ERISA ‘fiduciaries' of the medical portion of [the] Smith Construction employee welfare benefit plan.” (Dkt. 19 at 11; Dkt. 15 at 373 (“The Administrator for the Plan is Mid-America Associates and Liberty Union Life Assurance Company”).)

         The events giving rise to plaintiff's claim began on or about May 27, 2014, when plaintiff began bleeding uncontrollably from his nose. He went to the emergency room at Marquette General Hospital on May 31, 2014, where doctors cauterized his nose to stop the bleeding. The treatment was unsuccessful, so plaintiff returned to the emergency room the following day.

         Brunelle was then referred to Superior ENT for treatment. On June 3, 2014, he was treated at Superior ENT, but the bleeding did not cease. He returned on June 4, and the doctors attempted a different treatment with an inflatable balloon, instructing him to return in three days. However, the new treatment caused plaintiff to begin bleeding from his eye sockets, so he sought treatment again on June 5, at which point the physician recommended surgery.

         Plaintiff underwent surgery on June 6, 2014. The bleeding continued despite the procedure, and on June 11, 2014, plaintiff was admitted to Marquette General Hospital.

         Plaintiff's treating physician, Dr. Manish Kesliker, consulted with a hematologist on staff, and determined that plaintiff should be transferred to another hospital for diagnosis and treatment. (Dkt. 15 at 62.) Dr. Kesliker's records from June 12, 2014 show that the hematology department concluded that plaintiff “could not be treated at [Marquette General] as most of the labs . . . would need to be send-out [sic] labs and it would take several days to get the results, ” which would cause plaintiff to “be here unneededly.” (Id. at 62-63.) Thus, hematology recommended plaintiff be transferred, and Dr. Kesliker then contacted the University of Michigan, which agreed to accept him as a patient. (Id. at 63.) Plaintiff's treating physician also recommended that he be transferred by air ambulance, instead of ground ambulance.

         According to one transfer form, the benefits of the transfer were “availability of specialized services, facilities, diagnostic equipment, [and] personnel.” (Dkt. 15 at 67.) Further, the prehospital care report states that plaintiff needed to be transported “for clotting factor surgery not available at Marquette General.” (Dkt. 15-1 at 73.) A December 23, 2014 letter from Dr. Kesliker also states that the University of Michigan was recommended because Marquette General “did not have the capabilities to get the bleeding to stop, ” and the University of Michigan was “the closest facility to handle this coagulation problem.” (Dkt. 15 at 56.)

         Records from June 12, 2014 also indicate that Dr. Kesliker believed air transport should be used to avoid the risks of “traffic and inclement weather.” (Id.) The December 23, 2014 letter further explains that air ambulance was used because plaintiff “has a rising INR, hemoglobin had dropped nearly 2 grams in 18 hours after receiving multiple units of fresh frozen plasma, and an ambulance ride would take in excess of greater than 8 hours, ” which “increased his risk uneedingly [sic].” (Dkt. 15 at 56.) More specifically, plaintiff's symptoms indicated that the “risk of spontaneous bleeding was great, ” and he “was at increased risk for severe anemia, acute MI, flash pulmonary edema, and even death.” (Id.)

         After plaintiff was transferred to the University of Michigan hospital, he was diagnosed with a rare blood disorder, and successfully treated. On or about November 3, 2014, he filed a claim for medical benefits. On November 21, 2014, defendants agreed to pay the claim, except the $57, 950 bill for the air ambulance. (Dkt. 15-1 at 53-54.)

         In defendants' first notice of adverse benefits determination, dated July 20, 2015, the claim for the air ambulance was denied as not medically necessary. Defendants cited the findings of an independent physician reviewer to support the determination. (Dkt. 15-1 at 53-57.) The reviewer, obtained through the Medical Review Institute of America, Inc., was asked if there was “a specific lab test . . . that could only be provided by the University of Michigan hospital, ” and if the “medical records submitted meet plan definition of medical necessity for the air ambulance transfer.” (Id. at 56; Dkt. 15-1 at 78.) The reviewer answered both questions in the negative, stating that medical necessity had not been established because plaintiff “was hemodynamically stable, and there was no indication that ground transport would have placed the patient's health in jeopardy.” Further, (1) “[h]is bleeding was controlled”; (2) “[t]here were no weather considerations that would have been a contraindication for ground transport”; and (3) “Ann Arbor, MI was not the closest appropriate facility to treat his condition.” (Id. at 78-79.)

         On September 25, 2015, defendants issued a second and final adverse benefits determination, again concluding the air ambulance was not medically necessary. (Dkt. 15-1 at 6.) Defendants relied on the independent physician reviewer reports obtained from the Medical Review Institute of America, Inc. (also relied on in the first adverse determination) and Advanced Medical Reviews. (Id. at 9.) Both reviewers were asked nearly identical questions, and gave similar responses.

         The second reviewer, obtained through Advanced Medical Reviews, concluded that the air ambulance was not medically necessary because “plan language allows for a transfer to the nearest facility, ” which was not the University of Michigan hospital, and therefore the transfer was not “in accordance with the standards of good medical practice, cost-effective, [or] consistent with the [plaintiff's] diagnosis.” (Id. at 25.) Further, the second reviewer stated that the air ambulance was likely ...


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