Dupree v. Holman Professional Counseling Centers
Filed July 29, 2009
Cite as 07-55617

Plan not Ambiguous, Holder not Entitled to Reimbursement

Timothy Dupree (Dupree) was an employee of Beverly Hills Hotel (BHH). BHH contracted with Holman Professional Counseling Centers (Holman) for behavioral health insurance coverage of its employees.

The coverage provided, among others, that if enrollees choose to use non-contracted providers instead, they would do so at their own expense except as otherwise provided. The plan also excluded services performed by non-contracted providers except in emergency cases or as otherwise authorized by it.

When Dupree’s step-daughter, Alexandra Martini (Alexandra) succumbed to diabetes, her mother, Ms. Dupree approached Holman to get a residential treatment center (RTC). Holman provided Ms. Dupree two contracted information of RTCs. However, Ms. Dupree preferred another facility, Visions Adolescent Treatment Program (Visions). Alexandra’s doctors recommended to Holman that Alexandra be brought to Visions even if it was not covered by Dupree’s plan.

Despite Holman’s caution of Vision not being an “in-network” and Dupree’s plan not carrying an “Out-of-Plan benefit”, Alexandra was still admitted at Visions.

When Dupree asked Holman for reimbursement, Holman denied the same as an uncovered out-of plan benefit. Dupree and Ms. Dupree in different occasions appealed but Holman just reiterated its denial.

Consequently, Dupree filed a complaint in the district court. The district court ruled that Holman properly denied Dupree’s claim for using a non-contracted provider. Dupree filed an appeal.

The United States Court of Appeal, in affirming the district court’s decision, ruled that where an ERISA-covered policy for behavioral health coverage such as that provided by Holman (1) designated a specific provider, (2) repeatedly asserted that non-contracted provider services were not generally covered, (4) specifically listed certain covered benefits, and (5) did not specifically cover non-contracted residential treatment center services, such services were unambiguously not covered.

Hence, since the two contracted RTCs were declined to by Ms. Dupree, Alexandra’s treatment was not covered.