Court Cases of Interest

Court Rejects Health Plan’s Denial of Residential Treatment Coverage Due to Failure to Address Treating Provider’s Opinion

The District Court for the District of Utah ordered a health plan to reconsider a coverage denial for residential treatment due to the plan’s failure to “engage with and address” the opinion of the treating health care provider, D.B. v. United Healthcare Insurance Co.

The plaintiff’s son suffered from mental health issues and met with a psychologist who conducted an assessment involving nine separate testing sessions over a period of 28 days. At the conclusion of the assessment, the psychologist made several diagnoses and recommended long-term residential treatment. Shortly thereafter, the plaintiff’s son commenced two years of treatment at Triumph Youth Services, a residential treatment facility that provides in-patient treatment for adolescents with mental health and substance abuse issues.

During the two-year treatment period, the plaintiff was covered by two different health plans, one administered by Blue Cross Blue Shield of Illinois (BCBS) and one administered by United Healthcare (UHC). The UHC plan used United Behavioral Health (UBH) to administer its mental health coverage. Both BCBS and UBH denied coverage for the residential treatment at Triumph. The plaintiff did not pursue an internal appeal of the BCBS denial. However, he appealed the UBH denial, and his appeal was denied based on a purported lack of medical necessity. He subsequently filed a claim for benefits under ERISA in federal court. During the internal claims and appeal process with UBH, the plaintiff submitted a “specialty psychological evaluation” prepared by his son’s treating psychologist, together with additional medical records. However, UBH did not address any of the medical evidence in its denial letter. The court held that this failure to “engage with and address” the medical evidence, particularly the treating provider’s specialty psychological evaluation, was arbitrary and capricious. The court emphasized that “a plan administrator cannot shut its eyes to readily available information that could confirm a beneficiary's entitlement to benefits.” Accordingly, the court sent the case back to UBH to fully consider all of the medical evidence. This case demonstrates the importance of medical documentation when contesting a denial of benefits under a plan. Pilots who are subject to health or disability benefit denials should make sure to submit supportive documentation, including documentation from their treating medical provider as part of any appeal.

Are Pilots on Military Leave Due the Same Wages and Benefits Afforded to Pilots on Non-Military Leave?

On June 8, 2023, the United States Court of Appeals for the Eleventh Circuit (Eleventh Circuit) in Myrick v. City of Hoover, Alabama ruled that an employer violated the Uniformed Services Employment and Reemployment Rights Act (USERRA) by not providing employees on military leave the same benefits it provided to similarly situated employees on a comparable non-military leave.

USERRA entitles employees on military leave to the same rights and benefits, not determined by seniority, provided to similarly situated employees on non-military leave. USERRA considers factors such as status and pay when determining if two employees are similarly situated. To determine comparability, courts must compare the duration of the leave, the purpose of the leave, and the employees’ ability to choose when to take the leave.

In Hoover, the Eleventh Circuit affirmed the United States District Court for the Northern District of Alabama’s (District Court) ruling for summary judgment (ruling in favor of one party against another without a full trial) in favor of four City of Hoover police officers who were military reservists and summoned to active duty but did not receive wages, accrue leave, or receive holiday pay unlike police officers on administrative leave.

Here, the City of Hoover placed employees in one of two categories: paid status or unpaid status. Employees on the City’s payroll or using paid leave were on paid status and were able to accrue different types of leave and convert that leave to compensation and receive 8 hours of pay for 12 paid holidays per year. Employees on unpaid status could not accrue leave and did not receive holiday pay. Also, the City of Hoover provided 168 hours of annual paid military leave to employees absent for military service. During these hours, military employees remained on paid status, accrued leave, and received holiday pay. After the 168 hours, military employees were placed on unpaid status. Employees on administrative leave beyond 168 hours remained on paid status, accrued leave, and received holiday pay without restriction. During their periods of service, each of the four officers exhausted their 168 hours of paid status, did not accrue leave, and did not receive holiday pay while employees on administrative leave did. The four military reservists filed suit under USERRA. The four officers and the City of Hoover filed for summary judgment. The District Court ruled in favor of the officers’ motion. The City of Hoover appealed.

The Eleventh Circuit relied upon the DOL’s interpretation of status and pay to mean an employee’s position and salary prior to their leave status as opposed to while on leave. Based on this interpretation, the Eleventh Circuit found that the four military reservists held similar positions and earned similar salaries to officers on administrative leave; thus, the two groups of employees were similarly situated.

As part of the Eleventh Circuit’s comparability analysis, the Eleventh Circuit agreed that employees are placed on both military leave and administrative leave to serve a similar purpose—compliance with the law. The City of Hoover provides military leave to comply with USERRA, and employees are placed on administrative leave to comply with the notice and hearing requirements of the Due Process Clause. Additionally, both forms of leave are intended to shield employees from undue hardship.

With respect to an employee’s ability to choose when to take the leave, the Eleventh Circuit concluded that employees on military leave have no more ability to choose when to go on military leave than other employees can determine when they will be investigated and placed on administrative leave.

To compare duration, the Eleventh Circuit grouped military leave and administrative leave into two categories based on length: short-term leave and long-term leave. The court placed military leave for training and administrative leave for brief events like jury duty in the short-term leave category. The court found that the average duration for short-term military leave was about 37 days, while the average duration for short-term administrative leave was about 13 days. The Eleventh Circuit placed military leave for deployment and administrative leave for investigative purposes in the long-term category. The court found that the average duration for both forms of long-term leave was about 16 months. The Eleventh Circuit concluded that had the reservists been placed on administrative leave and not military leave, they would have accrued leave and received holiday pay for each period of service, including those shorter than 16 months. Thus, the Eleventh Circuit found that military leave and administrative leave were comparable and affirmed the District Court’s ruling in favor of the officers.

Key Takeaways

y USERRA requires employers to provide the same rights and benefits to pilots on military leave that they provide to similarly situated pilots on comparable forms of non-military leave.

y Most pilots hold either one of two positions and enjoy the same salary, with respect to their position, based on the terms of the collective bargaining agreement. Therefore, most military pilots are highly likely to be considered similarly situated to other pilots on non-military leaves.

y A comparability determination requires a facts and circumstances analysis that is individual to each pilot’s situation. Thus, determining whether a pilot on military leave is due wages or certain benefits obtained by a pilot on a non-military leave requires the employer to compare the duration of the leave, purpose of the leave, and pilots’ ability to choose when to take the leave of both sets of pilots.