Insurance – Coverage – ‘skilled nursing services’ – domiciliary care

Listen to this article

Insurance — Coverage — ‘skilled nursing services” — domiciliary care

Where a healthcare insurance plan excluded coverage for custodial care that does not require “skilled nursing,” the district court did not err by granting summary judgment in favor of the plan when it denied coverage for claims relative to an elderly patient’s multiple, chronic conditions leading up to her death.

“[U]nder the Plan, provision of ‘care by skilled nursing personnel’ is not the equivalent of the provision of ‘skilled nursing services.’ Ms. Becker has pointed to no language in the Plan that suggests that the mere presence of ‘skilled nursing personnel’ equates with the provision of ‘skilled nursing services,’ and the Summary Plan Description suggests otherwise. Coverage under the Plan depends entirely on the type of care received, not the qualifications of the nursing staff providing that care.

“Even if we assume that Ms. Becker’s medical expert employed the phrase ‘the care of skilled nursing personnel’ to mean the provision of ‘skilled nursing services,’ we would be faced with, at best, ‘a contest of competing medical opinions.’ Black v. Long Term Disability Ins., 582 F.3d 738, 745 (7th Cir. 2009). In such cases, the deferential standard of review requires that we accept ‘[the administrator’s] choice between competing medical opinions so long as it is rationally supported by record evidence.’ Id. Here, there is ample evidence to support the conclusion that Ms. Jeranek’s care at Nu-Roc did not involve the provision of care that had to ‘be furnished by or under the direct supervision of professionally trained and licensed nursing personnel,’ services that ‘require[d] specialized (professional) training,’ ‘observation and assessment’ of a patient’s medical needs or ‘supervision of a medical treatment plan involving multiple services where specialized health care knowledge must be applied in order to attain the desired medical results.’ There was more than an adequate basis for the Plan’s conclusion that the care provided was entirely custodial and domiciliary in nature.”

Affirmed.

No. 11-2624, Becker v. Chrysler LLC Health Care Benefits Plan, Eastern District of Wisconsin, Griesbach, J., Ripple, J.

Full Text