Muratore v. United States Office of Personnel Management

Christopher and Sharon Muratore (plaintiffs) participated in a health plan offered by PCA Health Plans of Florida (PCA) pursuant to a contract between PCA and the United States Office of Personnel Management (OPM) (defendant). Under the plan’s medical-benefits section, rehabilitative therapy, including speech therapy, was provided for up to two months, and long-term rehabilitative therapy was explicitly not covered. The plan’s mental-conditions benefits section provided for psychiatric treatment, including individual therapy, to the extent necessary for the treatment of mental illness or disorders. The plan also had a section governing prescription-drug benefits and limitations. The Muratores’ daughter had autism, and their daughter’s psychiatrist prescribed speech therapy for her. PCA covered the speech-therapy treatment for two months. After two months, PCA discontinued payment for the speech therapy pursuant to the limitation specified in the plan. Subsequently, the Muratores unsuccessfully appealed to OPM. After OPM’s denial, the Muratores filed suit in federal district court to challenge OPM’s decision. The district court granted the Muratores’ motion for summary judgment. OPM appealed. The parties agreed that autism was a mental-health disorder for purposes of the plan. OPM asserted that the medical-benefits section of the plan limited coverage for speech therapy to two months. The Muratores asserted that coverage for autism, a mental disorder, arose from the mental-conditions section and that speech therapy qualified as individual-therapy psychiatric treatment because it was prescribed by a psychiatrist. OPM argued that individual therapy implied the commonly understood meaning of the term, counseling by a psychiatrist. OPM routinely negotiated insurance contracts and interpreted health plans to determine an insurance provider’s liability.