Use this button to switch between dark and light mode.

Experience a New Era in Legal Research with Free Access to Lexis+

Eugene S. v. Horizon Blue Cross Blue Shield of N.J.

Eugene S. v. Horizon Blue Cross Blue Shield of N.J.

United States Court of Appeals for the Tenth Circuit

November 15, 2011, Filed

No. 10-4225

Opinion

 [*1128]  KELLY, Circuit Judge.

Plaintiff-Appellant Eugene S. appeals from the district court's denial of his motion to strike and entry of summary judgment in favor of Defendant-Appellee Horizon Blue Cross Blue Shield of New Jersey ("Horizon BCBSNJ" or "Horizon"). We have jurisdiction under 28 U.S.C. § 1291, and we affirm.

Background

Eugene S. sought coverage for his son A.S.'s residential treatment costs from his employer's ERISA benefits insurer. Aplt. App. 1-6. Horizon's delegated third-party plan administrator, Magellan Behavioral Health of New Jersey, LLC ("Magellan"), originally denied the claim and explained that Mr. S.'s son qualified for intensive outpatient treatment, but not for residential treatment. Magellan affirmed its initial denial of residential treatment benefits through several  [**2] appeals by both Mr. S. and the residential treatment center. On Mr. S.'s final appeal, Magellan approved and provided benefits for residential treatment between August 10 and November 2, 2006, but reiterated that Mr. S.'s son qualified for intensive outpatient treatment only between November 3, 2006 and June 12, 2007, and refused residential treatment benefits during that period. Id. Having exhausted his administrative appeals, Mr. S. filed this action challenging Horizon's denial of benefits under ERISA (29 U.S.C. § 1132(a)(1)(B)), on July 24, 2009. Id.

Mr. S. and Horizon filed cross-motions for summary judgment on July 6, 2010. Aplt. App. 12-13, 56-58. That same day, Horizon also filed a declaration, including the terms of Horizon's delegation of authority to Magellan to administer mental health claims in a Vendor Services Agreement ("VSA"). Aplt. App. 95a-134a. Mr. S. moved to strike that declaration as procedurally barred and untimely. Aplt. App. 238-244a. The district court denied the motion to strike, Aplt. App. 337-43, and granted Horizon summary judgment, Aplt. App. 323-36. The district court held that  [*1129]  an "arbitrary and capricious" standard of review applied, and that neither  [**3] Horizon nor Magellan had acted in an arbitrary or capricious manner in denying the contested claim. Aplt. App. 327-36.

On appeal, Mr. S. makes three arguments: first, that the district court erred by denying his motion to strike and allowing the VSA into evidence. Aplt. Br. 28-36. Second, that the district court erred in reviewing Horizon's2 denials of benefits under an arbitrary and capricious, rather than a de novo, standard. Aplt. Br. 36-45. Third, that Horizon improperly denied him benefits under the terms of his ERISA benefits plan. Aplt. Br. 46-60.

Read The Full CaseNot a Lexis Advance subscriber? Try it out for free.

Full case includes Shepard's, Headnotes, Legal Analytics from Lex Machina, and more.

663 F.3d 1124 *; 2011 U.S. App. LEXIS 22803 **; 52 Employee Benefits Cas. (BNA) 2432

EUGENE S., Plaintiff - Appellant, v. HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY, Defendant - Appellee.

Prior History:  [**1] APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF UTAH. (D.C. No. 09-CV-00101-DS).

Eugene S. v. Horizon Blue Cross Blue Shield of N.J., 2010 U.S. Dist. LEXIS 135718 (D. Utah, Dec. 22, 2010)Eugene S. v. Horizon Blue Cross Blue Shield of N.J., 2010 U.S. Dist. LEXIS 135756 (D. Utah, Dec. 22, 2010)

Disposition: AFFIRMED.

CORE TERMS

district court, benefits, residential, plan administrator, argues, terms, arbitrary and capricious, documents, conflicting interest, seal, dual-role, insurer, part of the plan, summary judgment, psychiatric, delegation, novo, deferential review, denial of benefits, standard of review, administrative record, treating physician, supplementation, confidential, deference, records

Pensions & Benefits Law, Judicial Review, Standards of Review, General Overview, Civil Procedure, Appeals, Abuse of Discretion, Defenses, Demurrers & Objections, Motions to Strike, Administrative Law, Administrative Record, Conflict of Interest Analysis, Handling of Claims, Scope of Review, Discovery & Disclosure, Disclosure, Sanctions, Summary Judgment Review, Standards of Review, Arbitrary & Capricious Review, De Novo Standard of Review, Business & Corporate Compliance, Pensions & Benefits Law, ERISA, Plan Establishment, Employee Benefit Plans, Claim Procedures, Discovery, Protective Orders