Appeal from the United States District Court for the Central District of California Philip S. Gutierrez, District Judge, Presiding D.C. No. CV-06-06826-PSG.
The opinion of the court was delivered by: Hall, Senior Circuit Judge
Argued and Submitted October 22, 2008 -- Pasadena, California
Before: Harry Pregerson and Cynthia Holcomb Hall, Circuit Judges, and David Alan Ezra,*fn1 District Judge.
Dissent by Judge Pregerson
Timothy Dupree ("Dupree") and Alexandra Martini ("Alexandra"), father and step-daughter, bring this ERISA appeal concerning whether or not Dupree's employee health plan covers Alexandra's stay at a residential treatment center ("RTC") that had no contract with insurer Holman Profes- sional Counseling Centers ("Holman"). The district court found that the stay was not covered. We have jurisdiction pursuant to 28 U.S.C. § 1291 and affirm.
A. The Behavioral Health Insurance Plan
Dupree's employer, Beverly Hills Hotel, contracted with Holman for behavioral health insurance coverage. Holman agreed to provide behavioral health services "through Providers pursuant to the Schedule of Benefits," allowing that, if enrollees chose to instead use non-contracted providers, they would do so at their own expense, "except as otherwise provided in this Group Plan Contract."*fn2 This language is echoed in other contract provisions: declining to provide reimbursement "except in emergency cases or as outlined in this Group Plan Contract," and declining to cover non-emergency treatment by non-contracted providers "unless otherwise stated in the Agreement." It also appears in the "Exclusions" section, which denies coverage for services performed by non-contracted providers except in emergency cases or as "other-wise authorized by the Plan." However, the plan also excludes coverage for "[a]ny service that is not specifically listed as a covered benefit."
The plan defines providers as licensed, experienced persons working individually or within a clinic who are "employed or under contract with Holman to deliver Behavioral Health Services to Enrollees." The definition section then distinguishes between contracted providers (those who have "contracted with Holman to deliver specified services") and non-contracted providers (those without such a contract), while cautioning that "Enrollees may be liable for the cost of non-emergency services provided by Non-Contracted Providers."
Most relevant to this appeal, the Holman plan includes care at a "Sub-Acute Care Facility," which is any RTC that "has entered into a provider agreement with Holman." In the benefit schedule, Category III, Section C (entitled "Residential Treatment, Transitional Care, Day Treatment, Partial Hospitalization") constitutes the RTC benefit provided for drug and alcohol treatment.*fn3 Category III also includes other sections detailing additional drug and alcohol treatment benefits: (A) "Outpatient," (B) "Contracted Providers-Inpatient Hospital," (D) "Non-Contracted Providers-Inpatient Hospital," and (E) "Non-Contracted Providers-Outpatient Services." ...