Jacqueline Fisher v. Aetna Life Insurance Company ( 2022 )

20-3148, 20-3804, 21-1
Jacqueline Fisher v. Aetna Life Insurance Company
UNITED STATES COURT OF APPEALS
FOR THE SECOND CIRCUIT
____________________
August Term, 2021
(Argued: October 20, 2021 Decided: April 22, 2022)
Docket Nos. 20-3148, 20-3804, 21-1
____________________
JACQUELINE FISHER,
Plaintiff-Appellant,
v.
AETNA LIFE INSURANCE COMPANY,
Defendant-Appellee. 1
____________________
Before: CALABRESI, POOLER, Circuit Judges, and KORMAN, 2 District Judge.
Plaintiff-Appellant Jacqueline Fisher appeals from two judgments entered
in the United States District Court for the Southern District of New York (Woods,
J., and Sullivan, J.) granting defendant Aetna Life Insurance Company judgment
on breach of contract claims under the Employee Retirement Income Security Act
1The caption is identical for the three docket numbers.
2Judge Edward R. Korman, United States District Court for the Eastern District
of New York, sitting by designation.
of 1974 (“ERISA”). Fisher also takes an interlocutory appeal from the non-final
order of the United States District Court for the Southern District of New York
(Woods, J.) granting judgment to Aetna. We heard these appeals in tandem.
Fisher contends that the insurance contract between the parties was governed by
a document provided on January 9, 2014 instead of February 19, 2014; that she is
entitled to a judgment based on Aetna’s miscalculation of her copay; that even if
the February 19 Document controls, the Patient Protection and Affordable Care
Act, 42 U.S.C. § 18022(c)(1) (“ACA”), provides that Aetna must apply the
individual out-of-pocket limit rather than the family out-of-pocket limit; and that
the brand-generic cost differential Fisher paid for her brand-name medication
should count toward her out-of-pocket limit.
We hold that (1) the February 19 document governed the contract of
insurance between the parties because Fisher was on inquiry notice as to its
terms; (2) Fisher is not entitled to a money judgment for her copay differential;
(3) the ACA does not provide that the annual limitation on cost sharing for self-
only coverage applies to all individuals regardless of whether the individual is
covered under an individual “self-only” plan or is covered by a plan that is other
than self-only for plans in effect prior to 2016; and (4) neither the ACA nor the
February 19 document required Aetna to apply the brand-generic cost
differential charge to Fisher’s out-of-pocket limit. We AFFIRM the district court
judgments.
Affirmed.
____________________
WILLIAM DUNNEGAN, Dunnegan & Scileppi LLC
(Laura Scileppi, Richard Weiss, on the brief), New York,
NY, for Plaintiff-Appellant.
EVAN YOUNG, Baker Botts L.L.P. (Earl B. Austin, on
the brief), New York, NY, for Defendant-Appellee.
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POOLER, Circuit Judge:
This case arises from three separate but related appeals of Jacqueline
Fisher, which we heard in tandem. First, Fisher appeals from the judgment of the
United States District Court for the Southern District of New York (Woods, J.)
granting judgment to Aetna Life Insurance Company on Count I of Fisher’s claim
for breach of contract under the Employee Retirement Income Security Act of
1974 (“ERISA”) regarding her 2014 health insurance plan with Aetna. Second,
Fisher appeals from the judgment of the district court (Sullivan, J.) granting
judgment to Aetna on Fisher’s claim for breach of contract under ERISA
regarding her 2015 health insurance plan. Third, Fisher takes an interlocutory
appeal from the non-final order of the district court (Woods, J.) ruling in favor of
Aetna on Count II of Fisher’s 2014 breach of contract claim under ERISA.
In Fisher’s complaint regarding her 2014 health insurance plan, Count I
alleged that the document Fisher received on January 9, 2014 (“January 9
Document”) was the governing health insurance contract between the parties
and Aetna breached that contract by failing to reimburse Fisher for her purchases
of EffexorXR, a brand-name antidepressant. Aetna argued that the insurance
contract was governed by the terms provided in a document Fisher received on
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February 19 (“February 19 Document”). The February 19 Document, unlike the
January 9 Document, contained a “Choose Generic” clause which required
insurees who elected to take a brand-name drug, to pay the price difference
between the brand-name drug and its generic equivalent. Count II alleged, in the
alternative, that even if the document Fisher received on February 19 governed
the health insurance contract between the parties, Aetna had breached that
contract by failing to reimburse Fisher for her purchases of EffexorXR.
Additionally, for both counts, Fisher alleged that Aetna breached its obligations
by failing to pay for Fisher’s purchases of EffexorXR after she met her out-of-
pocket limit.
The district court (Woods, J.) held a bench trial and called its own
witnesses. Ultimately, the district court granted judgment to Aetna on Count I.
The district court concluded that, because Fisher was on ‘inquiry notice,’ the
February 19 Document governed the contract of insurance between the parties.
Because the February 19 Document included a “Choose Generic” clause, Fisher
was required to pay the difference between EffexorXR and its generic equivalent.
Therefore, Aetna did not breach the contract by charging Fisher for the cost
difference between EffexorXR and its generic equivalent. As to Count II, the
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district court granted partial summary judgment to Aetna holding that Aetna
properly applied the family out-of-pocket limit to Fisher’s claims and that her
purchases of EffexorXR did not count toward her out-of-pocket limit.
Fisher brought a second complaint, this time regarding her 2015 health
insurance plan, which largely reprised her allegations in Count II. After
remanding to Aetna for a recalculation of Fisher’s benefits, the district court
(Sullivan, J.) granted summary judgment to Aetna holding that Fisher was not
entitled to a judgment for her copay differential and that the ACA was
ambiguous on whether the individual or family out-of-pocket limit applied to an
individual on a family health insurance plan, so the terms of the insurance
contract controlled.
Fisher appeals the decisions of the district courts, arguing that the district
courts erred in finding that she was on inquiry notice, that she is entitled to a
judgment for Aetna’s miscalculation of her copay differential, that the ACA
provided that the individual out-of-pocket limit applied to her, and that the ACA
required Aetna to apply the brand-generic cost differential charge to Fisher’s out-
of-pocket limit. We conclude the district court properly found that Fisher was on
inquiry notice because the terms of the February 19 Document were obvious and
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called to Fisher’s attention in the January 9 Document as well as through her
health insurance broker. We also agree that, because Aetna’s decision on remand
to award her the copay differential she requested was not arbitrary or capricious,
Fisher is not entitled to judgment. Moreover, because the language of the ACA is
ambiguous as to whether the individual out-of-pocket limit applies to an
individual on an other than self-only plan, we conclude the language of the
insurance contract controls and that the controlling regulations mandating
otherwise did not go into effect until 2016. Finally, the ACA does not provide
that Aetna apply the brand-generic cost differential to Fisher’s out-of-pocket
limit because her purchases of EffexorXR were not a covered service under the
terms of the ACA. Accordingly, we affirm the district courts’ grants of summary
judgment.
BACKGROUND
I. Dunnegan & Scileppi’s Health Insurance Plans
Fisher is the spouse of William Dunnegan, a name partner at Dunnegan &
Scileppi LLC (“D&S”), a New York based law firm. D&S offers health insurance
coverage to its employees (such as Dunnegan) and their beneficiaries (such as
Fisher) through a small business group insurance policy. In 2013, D&S had health
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insurance coverage through a policy issued by Oxford Health. Fred Warner, an
independent insurance broker who assisted D&S with selecting a group health
insurance policy, advised D&S that the Oxford policy was up for renewal, but
the deductible was projected to increase for 2014. Dunnegan worked with
Warner to find a new group health insurance plan for the firm. On November 25,
2013, Warner sent Dunnegan an email attaching a summary chart of various
group health plans for 2014. As an insurance broker, Warner had access to
various plan documents and details through multiple sources. D&S ultimately
selected a small business group plan from Aetna known as the Aetna New York
“Silver OAMC 2000 80/60 HSA PY” (“2014 Aetna NY Silver Plan”).
Under New York law, the Department of Financial Services (“DFS”)
regulates small business group health insurance plans in New York and all
health insurance providers are required to submit their small business policies
for DFS review and approval. DFS approved of the 2014 Aetna NY Silver Plan in
October 2013. Once approved, Aetna could not lawfully change the terms of the
plan without DFS approval.
On December 18, 2013, D&S and each of its six employees sent completed
applications for the 2014 Aetna NY Silver Plan to Warner. The application that
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Dunnegan executed on behalf of D&S contained, among other things, the
following provisions:
The plan documents, including the policy and certificate, will
determine the contractual provisions, including procedures,
exclusions, and limitations relating to the plan and will govern in the
event they conflict with any benefits comparison, summary or other
description of the plan.
...
. . . . I understand that this application will form a part of the Group
Agreement or Group Policy issued by Aetna, and by my signature
below I agree to be bound by the terms and conditions of that Group
Agreement or Group Policy.
No. 20-3148, App’x at 126.
II. January 9 Document and February 19 Document
On January 8, 2014, Aetna sent Warner an email to inform him that Aetna
had approved D&S’s application. On January 9, 2014, Aetna sent D&S a five-
page document titled “Final Rates.” This document contained general
information about the 2014 Aetna NY Silver Plan that D&S selected, including
the total monthly premium, coinsurance levels, and deductible. The January 9
Document disclosed that “[t]his preliminary rate sheet should be read in
conjunction with the more detailed benefit descriptions, exclusions and
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limitations, and underwriting guidelines contained in your product brochures.
For more information, please contact your licensed Agent or Sales
Representative.” No. 20-3148, App’x at 162. There were no other files attached to
the January 9 Document. Warner testified that the January 9 Document
“obviously” did not have every term and condition associated with the 2014
Aetna NY Silver Plan. No. 20-3148, App’x at 88, at 98:19-23. At trial, Dunnegan
testified that “when I originally got the [January 9 Document] handed to me by
[the office manager] on January 9th, my initial reaction was there’s more to this;
where’s the rest of it?” No. 20-3148, App’x at 110, at 482:20-22. D&S sent the
executed document to Aetna on January 9, 2014.
On February 19, Aetna mailed a form letter to D&S enclosing a document
purporting to be a group insurance policy. The February 19 Document did not
deviate from the model language approved by DFS. Before February 19, 2014, the
draft of the February 19 Document existed only in electronic form and was not
publicly available. But detailed information about the plan was available to
Aetna employees beginning in November 2013, after the plans had been
approved by DFS. Aetna employees could access this information to answer
questions about benefits under the 2014 Aetna NY Silver Plan.
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III. Fisher’s EffexorXR Prescription
The February 19 Document included the following clause:
An additional charge may apply when a Prescription Drug on a
higher tier is dispensed at Your or Your Provider’s request, when a
chemically equivalent Prescription Drug is available on a lower tier
unless We approve coverage at the higher tier. You will have to pay
the difference between the cost of the Prescription Drug on the higher
tier and the cost of the Prescription Drug on the lower tier. The cost
difference must be paid in addition to the lower tier Copayment or
Coinsurance.
No. 20-3148, App’x at 334. This is widely known in the health insurance industry
as a “Choose Generic” provision. Under a Choose Generic provision, a member
must first try the generic version of a medication before Aetna will approve the
brand-name equivalent. If the member chooses the brand-name drug, without a
waiver of the Choose Generic requirement, then the member must pay an
additional charge equal to the difference in cost between the brand-name and the
generic. The member can request a waiver of the Choose Generic provision, but
Aetna requires the member’s doctor to provide documentation showing that the
brand-name drug is medically necessary. This Choose Generic clause was not
present in the January 9 Document.
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Fisher suffered from severe recurrent major depression and was prescribed
EffexorXR. EffexorXR is a brand-name drug for which a generic, venlafaxine,
exists. The Aetna Formulary, Aetna’s prescription drug guide, classified
EffexorXR as a Tier 3 drug, which meant it was subject to the Choose Generic
provision. The cost of a 30-day supply of EffexorXR ranged from $350-$500 while
the cost of venlafaxine was $35. Fisher submitted a prescription for EffexorXR on
January 29, 2014, but Aetna declined to cover Fisher’s EffexorXR prescription.
Fisher’s doctor submitted a form requesting Aetna cover EffexorXR which Aetna
then approved. Importantly, however, Aetna did not waive the additional charge
applicable to the brand-name drug. Aetna acknowledged that EffexorXR was
“approved for coverage” but did not approve additional reimbursement for it.
No. 20-3148, App’x at 63-64, ¶ 79. This approval allowed Fisher to purchase
EffexorXR at her pharmacy at Aetna’s negotiated price, but did not permit Fisher
to receive reimbursement for her purchases.
Fisher’s pharmacy submitted claims to Aetna on behalf of Fisher for the
price of EffexorXR. Aetna created records showing that Fisher had to pay for the
prescription and posted the records to a website accessible to Fisher. The
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maximum amount Fisher’s family paid for medical products or services in 2014
that could count toward their out-of-pocket limit was $8,951.14.
Fisher continued to purchase EffexorXR in 2015 when she was on a new
health policy administered by Aetna. The 2015 policy contained the same Choose
Generic clause as the February 19 Document. Aetna applied the full cost of
Fisher’s January, February, March, and April purchases of EffexorXR ($540.11
each) to her 2015 deductible. Fisher asserts she met her deductible on May 4,
2015, but Aetna did not reimburse her for any costs after that date. On August 31,
2015, Fisher’s purchase of EffexorXR took her annual medical spending over
$6,000 which she alleges is above her out-of-pocket limit, but Aetna still refused
to cover Fisher’s purchases of EffexorXR for the rest of 2015.
IV. Fisher’s Appeal Within Aetna
In August 2014, Dunnegan and Warner contacted Aetna about its
decisions concerning coverage of EffexorXR. Aetna informed them that if Fisher
and her doctor submitted a medical-necessity waiver of the Choose Generic
clause, Aetna may approve and cover EffexorXR retroactively. Dunnegan
initially sent a fax to Fisher’s doctor, Dr. Rosenfeld, requesting he call Aetna, but
just two days later, sent another fax instructing Dr. Rosenfeld to disregard the
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previous one because “Aetna has no interest in making an honest interpretation
of its policy and . . . talking to [Aetna] is a waste of time.” No. 20-3148, App’x at
416. Dunnegan, instead, submitted an appeal within Aetna on September 8, 2014.
Aetna denied the appeal and instead of filing a second-level appeal, Fisher sued
Aetna on behalf of herself and all others similarly situated.
V. Procedural History
A. Fisher’s First Suit - 2014 Health Insurance Plan
1. Initial Proceedings
On January 15, 2015, Fisher filed a complaint against Aetna asserting two
claims for damages under ERISA. Count I alleged that the January 9 Document
was the governing health insurance contract between the parties and that Aetna
had breached that contract by failing to reimburse Fisher for her purchases of
EffexorXR. Count II alleged, in the alternative, that even if the February 19
Document governed the health insurance contract between the parties, Aetna
breached that contract by failing to reimburse Fisher for her purchases of
EffexorXR. Additionally, for both counts, Fisher alleged that Aetna breached its
obligations by failing to pay for Fisher’s purchases of EffexorXR after she met her
out-of-pocket limit.
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The parties moved for summary judgment. On July 29, 2016, the district
court (Woods, J.) denied Fisher’s summary judgment motion. The district court
conducted a bench trial and called its own witnesses. The court called three
witnesses from March 8, 2017 to March 10, 2017: (1) Warner; (2) Karen Pribush, a
former Aetna employee; and (3) Dunnegan.
2. Count I
On May 29, 2020, the district court issued a decision, making various
findings of fact and concluding that Aetna was entitled to judgment on Fisher’s
first breach of contract claim. Fisher v. Aetna Life Ins. Co. (“Fisher I”), No. 1:15-CV-
283-GHW, 2020 WL 2792994, at *13 (S.D.N.Y. May 29, 2020). The court did not
rule on Count II of Fisher’s claim for breach of the February 19 Document
because Aetna had not moved for judgment on that claim.
The factual determinations by the district court included finding Warner’s
testimony that he could not retrieve a summary of benefits of the health
insurance plan not credible, finding Dunnegan’s belief that the January 9
Document constituted D&S’s entire Aetna insurance policy not credible, and
finding that Dunnegan and D&S were on inquiry notice of the terms of the
February 19 Document after they received the January 9 Document. The court
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found that Aetna intended to offer an insurance contract with the terms of the
February 19 Document, it was obvious to D&S that Aetna had offered to provide
health insurance on the terms set forth in the February 19 Document, and D&S
could have learned the “material terms” of the February 19 Document by calling
Aetna. Fisher I, 2020 WL 2792994, at *8.
3. Count II
With respect to Fisher’s second claim that Aetna breached the terms of the
February 19 Document, the district court (Woods, J.) issued a memorandum
opinion and order on August 12, 2020. Fisher v. Aetna Life Ins. Co. (“Fisher II”), 478
F. Supp. 3d 489, 491 (S.D.N.Y. 2020). The district court granted partial summary
judgment to Fisher because Aetna charged Fisher more than it should have when
it applied the coinsurance applicable to non-preferred brands instead of the
lower copay applicable to generic drugs once Fisher met her deductible which
amounted to a difference of $179.76. Aetna conceded it had miscalculated the
coinsurance/copayment scheme for Fisher’s EffexorXR prescriptions. The district
court dismissed the remainder of Count II, concluding that the ACA did not
require insurers to apply the individual out-of-pocket limit to individuals on
family health insurance plans and that Fisher’s purchases of EffexorXR were not
15
a covered service under the ACA. However, the district court certified the
questions concerning the out-of-pocket limit under the ACA for interlocutory
review pursuant to 28 U.S.C. § 1292(b). 3 This interlocutory appeal is docket no.
21-1-cv.
B. Fisher’s Second Suit – 2015 Health Insurance Plan
1. Remand to Aetna
On January 8, 2016, Fisher brought another complaint against Aetna,
largely reiterating Count II from her first complaint. The parties filed cross-
motions for summary judgment. On March 31, 2017, a few weeks after the bench
trial concluded for Fisher’s first complaint, another district court (Sullivan, J.)
3 Because Fisher intended to move for class certification regarding the partial
relief she was granted by the district court (Woods, J.) in its August 13, 2020
order, the district court did not enter judgment on Fisher’s second claim at the
time. However, the district court did not delay entering judgment on Fisher’s
first claim because of the potential inefficiencies that could result if Fisher
successfully certified a class under her second claim which assumed the February
19 Document is the binding contract. If this Court reversed the district court’s
finding that the February 19 Document is a binding contract, then that would
have required the decertification of a class based on the February 19 Document
and the certification of a new class based upon the January 9 Document. To avoid
such inefficiencies, the district court issued a Rule 54(b) certification for Fisher’s
Count I claim and certified the entirety of the district court’s decision on Count II
for interlocutory appeal under 28 U.S.C. § 1292(b).
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granted Fisher partial summary judgment on her second complaint. The district
court held that Aetna’s denial of Fisher’s request for coverage of her purchases of
EffexorXR was arbitrary and capricious. Fisher v. Aetna Life Ins. Co., No. 16-CV-
144 (RJS), 2017 WL 1246133, at *6 (S.D.N.Y. Mar. 31, 2017). However, rather than
grant Fisher an award, the district court vacated Aetna’s denial of benefits and
remanded to Aetna for reconsideration of Fisher’s claims. Id.On remand, Aetna, among other things, reversed its decision not to
reimburse Fisher for the copay differential—the difference between the cost of
venlafaxine ($18.04 per month) and the copayment for venlafaxine ($10 per
month), totaling $64.32 for the period between May and December 2015.
Additionally, Aetna determined it mistakenly applied the Choose Generic cost
differential—the difference between EffexorXR’s cost and venlafaxine—to her
deductible which provided Fisher an unwarranted windfall by allowing her to
meet her deductible earlier than she would have otherwise. However, Aetna
decided not to reverse the miscalculation of Fisher’s deductible. On April 30,
2018, Aetna mailed a check for $64.32 to Fisher’s attorney, and did so again on
May 1, 2018. Fisher’s attorney returned both checks without depositing them.
2. March 31, 2019 Order
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On April 16, 2018, Fisher filed another motion for summary judgment
arguing that she was entitled to a judgment of $64.32, that her prescription for
EffexorXR was medically necessary and should have been covered, and that she
was entitled to all amounts she spent in excess of her out-of-pocket limit. Aetna
filed a cross-motion for summary judgment.
On March 31, 2019, the district court (Sullivan, J.) denied Fisher’s motion in
its entirety and granted summary judgment to Aetna. Fisher v. Aetna Life Ins. Co.
(“Fisher III”), No. 16-cv-144 (RJS), 2019 U.S. Dist. LEXIS 233798, at *20 (S.D.N.Y.
Mar. 31, 2019). The district court held that the deferential standard under ERISA
precludes a judgment in favor of Fisher because Aetna agreed to pay the copay
differential of $64.32. Id. at *18. The court found Aetna had already sent Fisher
two checks for that amount and granted her the exact relief she requested, so
Aetna’s decision was not arbitrary and capricious. Id. Second, the district court
held that the 2015 insurance contract clearly indicated that the family out-of-
pocket limit applied to Fisher. Id. at *14-15. In response to Fisher’s alternative
argument that the ACA required Aetna to apply the lower, individual limit, the
district court held that the clear language of the policy applies. Id. at *17. The
district court did not reach the issue of whether EffexorXR was approved as
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“medically necessary” and should have been reimbursed after Fisher met the
out-of-pocket limit because Fisher did not meet the out-of-pocket limit for her
family plan in 2015. Id. at *19-20.
3. Motion for Reconsideration
Fisher then moved for reconsideration of the district court’s March 31, 2019
order, arguing that the court erred in its interpretation of the ACA and that she is
entitled to a judgment against Aetna for the copay differential of $64.32. On
October 5, 2020 the district court (Sullivan, J.) denied Fisher’s motion for
reconsideration. Fisher v. Aetna Life Ins. Co., No. 16-CV-144 (RJS), 2020 WL
5898788 (S.D.N.Y. Oct. 5, 2020). The district court concluded that the ACA does
not speak to whether the individual or family out-of-pocket limit applies to an
individual covered by a family policy. The district court considered a final rule
(“2015 Rule”) passed by the U.S. Department of Health and Human Services
(“HHS”). HHS determined that, beginning in 2016, insurance providers could
not require any individual, including those with family coverage, to spend more
than the individual out-of-pocket limit established under the Act – a limitation
commonly known as an “embedded individual out-of-pocket limit.” Fisher, 2020
WL 5898788, at *4. Significantly, the district court held that the 2015 Rule was a
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legislative rule instead of an interpretive rule, and therefore, it did not apply
retroactively to Fisher’s 2014 and 2015 health insurance plans. Accordingly, the
plain text of the 2015 health insurance plan controlled, and the plan clearly stated
Fisher was obligated to meet the family out-of-pocket limit.
DISCUSSION
I. Standard of Review
We review a district court’s grant or denial of summary judgment de novo.
Rivkin v. Century 21 Teran Realty LLC, 494 F.3d 99, 103 (2d Cir. 2007). For issues
concerning statutory interpretation, such as the interpretation of 42 U.S.C. §
18022, the standard of review is also de novo. United States v. Epskamp, 832 F.3d
154, 160 (2d Cir. 2016).
Additionally, we review de novo a district court’s determination that the
parties agreed to a contract. Soliman v. Subway Franchisee Advert. Fund Tr., Ltd.,
999 F.3d 828, 833 (2d Cir. 2021); see also Shann v. Dunk, 84 F.3d 73, 77 (2d Cir.
1996) (“The central issue—whether, based on the factual findings, a binding
contract existed—is a question of law that we review de novo.”). However, we
review a district court’s findings of fact bearing on this question under a “clearly
erroneous” standard. Specht v. Netscape Commc’ns Corp., 306 F.3d 17, 26 (2d Cir.
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2002). A district court’s findings of fact pursuant to a bench trial, “whether based
on oral or documentary evidence, shall not be set aside unless clearly erroneous,
and due regard shall be given to the opportunity of the trial court to judge [] the
credibility of the witnesses.” Presley v. U.S. Postal Serv., 317 F.3d 167, 174 (2d Cir.
2003) (citing Fed. R. Civ. P. 52(a)). A finding of fact is “clearly erroneous when
although there is evidence to support it, the reviewing court on the entire
evidence is left with the definite and firm conviction that a mistake has been
committed.” Anderson v. City of Bessemer City, N.C., 470 U.S. 564, 573 (1985)
(internal citation and internal quotation marks omitted).
II. Governing Contract for Insurance
The primary issue on Fisher’s first appeal is whether the January 9 or
February 19 Document was the governing contract of insurance between D&S
and Aetna. The parties agree that a contract of insurance existed between D&S
and Aetna for the policy year 2014, but disagree as to whether the January 9
Document is the governing policy, as Fisher claims, or the February 19
Document is the governing policy, as Aetna claims.
“It is a basic tenet of contract law that, in order to be binding, a contract
requires a ‘meeting of the minds’ and ‘a manifestation of mutual assent.’” Starke
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v. SquareTrade, Inc., 913 F.3d 279, 288-89 (2d Cir. 2019) (quoting Express Indus. &
Terminal Corp. v. N.Y. Dep’t of Transp., 93 N.Y.2d 584, 589 (N.Y. 1999)). “The
manifestation of mutual assent must be sufficiently definite to assure that the
parties are truly in agreement with respect to all material terms.” Id. at 289. As a
general matter, courts look to the basic elements of the offer and acceptance to
determine if there was an objective meeting of the minds sufficient to create a
binding and enforceable contract. See Express Indus., 93 N.Y.2d at 589.
“Where an offeree does not have actual notice of certain contract terms, he
is nevertheless bound by such terms if he is on inquiry notice of them and
assents to them through conduct that a reasonable person would understand to
constitute assent.” Starke, 913 F.3d at 289 (emphasis in original). “In determining
whether an offeree is on inquiry notice of contract terms, New York courts look
to whether the term was obvious and whether it was called to the offeree’s
attention.” Id. “While it may be the case that many users will not bother reading
the additional terms, that is the choice the user makes; the user is still on inquiry
notice.” Meyer v. Uber Techs., Inc., 868 F.3d 66, 79 (2d Cir. 2017).
The district court (Woods, J.) found that Dunnegan was on inquiry notice
of the terms of the February 19 Document. Fisher I, 2020 WL 2792994, at *7. We
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review this factual finding for clear error. See Healy v. Rich Prod. Corp., 981 F.2d
68, 73 (2d Cir. 1992) (“A district court's findings with respect to the expression of
the contracting parties’ intent will not be disturbed unless they are clearly
erroneous.”); Nicosia v. Amazon.com, Inc., 834 F.3d 220, 238 (2d Cir. 2016)
(“Whether particular notice was reasonable is ordinarily a question of fact for the
jury.”). “Under the clear error standard, we may not reverse [a finding] even
though convinced that had [we] been sitting as the trier of fact, [we] would have
weighed the evidence differently.” Atl. Specialty Ins. Co. v. Coastal Env’t Grp. Inc.,
945 F.3d 53, 63 (2d Cir. 2019) (alterations in original) (internal citations and
quotations marks omitted).
We agree with the district court’s (Woods, J.) finding that Fisher had
reasonable notice of the terms of the February 19 Document. Under New York
law, DFS regulates small business group health insurance plans in the state.
Aetna was required to submit all of its New York small business policies for 2014
to DFS for approval. DFS approved the language of the 2014 Aetna NY Silver
Plan on October 21, 2013. When Dunnegan signed and returned the January 9
Document, DFS had already approved of the language of the 2014 Aetna NY
Silver Plan. The language of the February 19 Document did not differ from the
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language approved by New York state in October 2013, so the terms of the
insurance plan existed as of October 21, 2013.
To determine whether D&S had inquiry notice of the terms of the February
19 Document, we consider whether the terms were “obvious” and “called to
[D&S’s] attention.” Starke, 913 F.3d at 289. “This often turns on whether the
contract terms were presented to the offeree in a clear and conspicuous way.” Id.
The January 9 Document that D&S signed and executed stated that “[t]his
preliminary rate sheet should be read in conjunction with the more detailed
benefit descriptions, exclusions and limitations, and underwriting guidelines
contained in your product brochures. For more information, please contact your
licensed agent or Sales Representative.” No. 20-3148, App’x at 162. Additionally,
the January 9 Document stated that D&S was purchasing an “NY Silver OAMC
2000 80/60 HSA PY” with plan ID 14018895. No. 20-3148, App’x at 160.
Furthermore, D&S employees filled out applications for insurance with Aetna in
December 2013 that stated “[t]he plan certificate of coverage will determine the
rights and responsibilities of member(s). It will govern in the event they conflict
with any benefits comparison, summary or other description of the plan.” No.
20-3148, App’x at 129. The same application also included the following
24
language: “I understand that this application will form a part of the Group
Agreement or Group Policy issued by Aetna, and by my signature below I agree
to be bound by the terms and conditions of that Group Agreement or Group
Policy.” No. 20-3148, App’x at 126. Additionally, Dunnegan signed the contract
with Oxford Health for D&S’s health insurance for 2013. That insurance plan was
over 140 pages. In contrast, the January 9 Document is only five pages. Because
the January 9 Document repeatedly indicated that additional terms existed and
because Dunnegan, as a sophisticated party, was aware that the January 9
Document was incredibly short relative to the prior contract of insurance that he
signed, it is “obvious” that the 2014 Aetna NY Silver Plan included additional
terms than those found in the January 9 Document.
Put simply, the terms of the February 19 Document were clearly called to
D&S’s attention. Both the application for insurance and the January 9 Document
indicated that additional terms existed. At any point, D&S could have called
Aetna and requested the additional terms because the language of the plan had
already been approved by DFS.
The district court’s factual findings on inquiry notice are sound and far
from the clear error required for this Court to reverse. See Anderson, 470 U.S. at
25
573–74 (“If the district court's account of the evidence is plausible in light of the
record viewed in its entirety, the court of appeals may not reverse it even though
convinced that had it been sitting as the trier of fact, it would have weighed the
evidence differently.”). We agree with the district court that the terms of the
February 19 Document were obvious and were called to D&S’s attention.
Therefore, Fisher, through D&S, was on inquiry notice of the terms of the
February 19 Document and the February 19 Document governs the contract of
insurance between the parties. 4
Fisher’s arguments to the contrary are unavailing. She argues that inquiry
notice cannot apply in this case, relying on Starke, 913 F.3d 279. In Starke, the
plaintiff bought a protection plan online for his CD player. Id. at 282.
SquareTrade sent Starke a service contract via email containing a chart setting
forth the material terms of the protection plan. Id. at 284. The body of the email
4We note, however, that, under New York law, inquiry notice calls for a highly
fact-specific inquiry. See, e.g., Blossom v. Dodd, 4 Hand 264 (N.Y. 1870); Tri-City
Renta-Car v. Vaillancourt, 304 N.Y.S.2d 682 (N.Y. App. Div. 1969). Accordingly, its
application may not be appropriate in cases where the circumstances materially
differ from those at issue here, where, for example, the offeree is an
unsophisticated party, or where the relevant terms are not diligently and
conspicuously called to the offeree’s attention by the offeror.
26
did not refer to arbitration, and the email “did not contain or refer to any
attachments.” Id. at 285-86. The bottom of the e-mail included a hyperlink to
“Terms and Conditions” which contained an arbitration clause. Id. at 285.
SquareTrade never directed Starke’s attention to the Terms and Conditions
hyperlink that contained the arbitration clause. Additionally, we found that the
SquareTrade email did not signal to Starke that he should click on the link, and
that he would be agreeing to the contract terms in the document to be found by
clicking the hyperlink. Id. at 293. We held that based on the totality of the
circumstances, Starke did not have inquiry notice of the arbitration clause.
Starke is readily distinguishable. Starke involved an online consumer
contract, not a small business health insurance plan. D&S was a sophisticated
party who used a broker, Warner, to determine the best health insurance plan for
them. Both D&S and Warner should have realized that the five-page January 9
Document could not possibly contain the full terms of the insurance contract.
Unlike Starke, this case did not involve a hidden arbitration clause tucked away
in a hyperlink. Here, the application for insurance and the January 9 Document
stated on their face that additional terms existed. As the district court found, “it
27
is not credible that Dunnegan believed the [January 9] document constituted his
entire Aetna insurance policy.” Fisher I, 2020 WL 2792994, at *6.
Fisher also argues that the district court erred in its interpretation of New
York Insurance Law § 3204. Section 3204 states: “Every policy of life, accident or
health insurance, or contract of annuity, delivered or issued for delivery in this
state, shall contain the entire contract between the parties, and nothing shall be
incorporated herein by reference to any writing, unless a copy thereof is
endorsed upon or attached to the policy or contract when issued.” N.Y. Ins. Law
§ 3204(a)(1). But this subsection “does not apply to a table or schedule of rates,
premiums or other payments which is on file with the superintendent for use in
connection with such policy or contract.” Id. § 3204(b).
Fisher argued below that the contract Aetna provided violated New York
law because New York law states that all contracts for insurance must contain
the full terms of the contract, unless a contract is a “schedule of rates” “on file”
with the state. Fisher argues that the January 9 Document did not fit this
exception because it was not on file with the state, and that Aetna therefore
violated Section 3204. The district court held that the exception in Section 3204(b)
28
applied because the January 9 Document was a “schedule of rates” that was on
file with the state.
Fisher is incorrect. The actual rates from the 2014 Aetna NY Silver Plan
were on file with DFS. At trial, Karen Pribush, an Aetna sales manager, testified
that the rates in the January 9 Document were filed with the State of New York
for the plan at issue here. Additionally, Aetna’s 2014 rate filing is publicly
available on the DFS website, which shows that the rates for the 2014 Aetna NY
Silver Plan were filed in May 2013. 5 Therefore, the January 9 Document was a
“schedule of rates” “on file with” DFS, and the exception in Section 3204(b)
applies.
III. Copay Differential Judgment
The district court (Sullivan, J.) held that Fisher is not entitled to a judgment
for her copay differential because Aetna’s decision was not arbitrary or
capricious. Fisher III, 2019 U.S. Dist. LEXIS 233798, at *19. “[W]hen the terms of a
5 See N.Y. Dep’t of Fin. Servs., Filing at a Glance: Aetna Life Ins. Co. 1, 210-11,
https://myportal.dfs.ny.gov/documents/538523/1230191/Aetna+Life+
Insurance+Co.+NY_SG+EPO_AETN-128993202.pdf. “[W]e may properly take
judicial notice of this document . . . because [it] is publicly available and its
accuracy cannot reasonably be questioned.” Apotex Inc. v. Acorda Therapeutics,
Inc., 823 F.3d 51, 60 (2d Cir. 2016).
29
plan grant discretionary authority to the plan administrator, a deferential
standard of review remains appropriate even in the face of a conflict.” Conkright
v. Frommert, 559 U.S. 506, 512 (2010). Applying this standard, an administrator
abuses its discretion where its decision was “without reason, unsupported by
substantial evidence or erroneous as a matter of law.” Fay v. Oxford Health Plan,
287 F.3d 96, 104 (2d Cir. 2002) (internal citations and quotation marks omitted).
Under ERISA, “a plan administrator’s decision is intended to be final—within
the bounds of the highly deferential arbitrary-and-capricious standard—and not
merely an input with the potential to assist the Court in making the ultimate
determination.” Roganti v. Metro. Life Ins. Co., 786 F.3d 201, 217 (2d Cir. 2015)
(internal citation and internal quotation marks omitted.)
Here, Aetna agreed to pay Fisher the copay differential of $64.32. She did
not argue below, and does not attempt to argue on appeal, that this decision was
arbitrary and capricious because the parties agreed that the benefits
determination correctly construed the policy. Fisher III, 2019 U.S. Dist. LEXIS
233798, at *18. Put simply, there is no reason to upend Aetna’s administrative
decision to provide Fisher with the relief that she requested. Although Fisher
30
would like to receive a judgment granting her the exact relief that Aetna has
already thrice attempted to provide, Fisher is not entitled to such a judgment. 6
IV. Out-of-Pocket Limit Under the Affordable Care Act
A. Statutory Text
In Fisher III, the district court (Sullivan, J.) held that Fisher was required to
satisfy the family out-of-pocket limit under the terms of the insurance plan,
rejecting Fisher’s argument that she need only reach the individual limit. First,
the district court held that the plain meaning of the health insurance contract
indicates that the family out-of-pocket limit applied to Fisher’s claims. Fisher III,
2019 U.S. Dist. LEXIS 233798, at *13. Second, the district court (Sullivan, J.), on
Fisher’s motion for reconsideration, held that its decision comported with the
ACA’s cost-sharing provision found at 42 U.S.C. § 18022(c). Fisher, 2020 WL
5898788, at *6. Fisher argues that the district court erred in its statutory
6Aetna provided Fisher with two checks for $64.32. Fisher returned both,
presumably because she was concerned the language accompanying the checks
could have been construed as a settlement of her claims. Following the district
court’s lead, Aetna sent a new check to Fisher, who declined to cash that check as
well.
31
interpretation in her appeals concerning both the 2014 and 2015 health insurance
plans.
To determine whether the ACA requires individuals to meet the
individual out-of-pocket limit even where those individuals are part of a family
plan, “we start our analysis . . . with the language of the statute.” Tanvir v.
Tanzin, 894 F.3d 449, 459 (2d Cir. 2018) (ellipses in original) (quoting Chai v.
Comm’r of Internal Revenue, 851 F.3d 190, 217 (2d Cir. 2017)). “Where the statutory
language provides a clear answer, our analysis ends there.” Id. (citation and
internal punctuation omitted). “The plainness or ambiguity of statutory language
is determined by reference to the language itself, the specific context in which
that language is used, and the broader context of the statute as a whole.” Id.(quoting Robinson v. Shell Oil Co., 519 U.S. 337, 341 (1997)).
42 U.S.C. § 18022(c)(1)(A) provides:
The cost-sharing incurred under a health plan with respect to self-only
coverage or coverage other than self-only coverage for a plan year
beginning in 2014 shall not exceed the dollar amounts in effect under
section 223(c)(2)(A)(ii) of Title 26 for self-only and family coverage,
respectively, for taxable years beginning in 2014.
26 U.S.C. § 223(c)(2), concerning “High deductible health plan[s],” provides:
(A) In general.—The term ‘high deductible health plan’ means a health
32
plan—
(i) which has an annual deductible which is not less than—
(I) $1,000 for self-only coverage, and
(II) twice the dollar amount in subclause (I) for family
coverage, and
(ii) the sum of the annual deductible and the other annual out-of-
pocket expenses required to be paid under the plan (other than
for premiums) for covered benefits does not exceed—
(I) $5,000 for self-only coverage, and
(II) twice the dollar amount in subclause (I) for family
coverage.
The district court (Sullivan, J.) concluded that the ACA is silent on the
question of which limit – individual or family – applies to an individual covered
under a family policy. We agree. The text of the ACA does not provide any
direction about whether the individual or family limit applies to an individual
covered by a family policy. Therefore, we turn to the applicable regulations for
guidance.
B. 2015 Rule
On February 27, 2015, HHS passed a final rule (the “2015 Rule”)
concerning benefit and payment parameters for health insurance plans in 2016:
Lastly, in the proposed rule, we proposed clarifying that the annual
limitation on cost sharing for self-only coverage applies to all individuals
regardless of whether the individual is covered by a self-only plan or is
covered by a plan that is other than self-only. In both of these cases, an
individual's cost sharing for [essential health benefits] may never exceed
33
the self-only annual limitation on cost sharing. For example, under the
proposed 2016 annual limitation on cost sharing, if an other than self-only plan
has an annual limitation on cost sharing of $10,000 and one individual in
the family plan incurs $20,000 in expenses from a hospital stay, that
particular individual would only be responsible for paying the cost
sharing related to the costs of the hospital stay covered as [essential health
benefits] up to the annual limit on cost sharing for self-only coverage
(assuming an annual limitation of $6,850 for 2016, the maximum for that
year). We sought comments on these proposed requirements and
clarifications as well as whether other requirements and clarifications were
needed. We are finalizing our proposal that the annual limitation on cost sharing
for self-only coverage applies to all individuals regardless of whether the
individual is covered by a self-only plan or is covered by a plan that is other than
self-only and the technical correction we proposed to make to the text at §
156.130(c).
Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment
Parameters for 2016, 80 Fed. Reg. 10750 (Feb. 27, 2015) (emphasis added). HHS
determined that insurance providers could not require an individual on a family
plan to spend more than the individual out-of-pocket limit established under the
ACA. This reading of the ACA comports with Fisher’s argument that she needed
to only meet the individual out-of-pocket limit even though she was on a family
plan. However, HHS made clear in the 2015 Rule that the regulation applied only
in 2016 and onward. See id. (“[U]nder the proposed 2016 annual limitation on
cost sharing . . .”); see also 80 Fed. Reg. at 10825 (“We note that 2016 plans must
comply with this policy.”).
34
The question, then, is whether the 2015 Rule can be applied retroactively to
Fisher’s 2014 and 2015 health insurance plans. To determine that, we must
answer whether the 2015 Rule is a legislative or interpretive rule. Whether a rule
is legislative or interpretive implicates whether the rule can be given retroactive
effect. “The distinction between legislative and interpretive rules derives from
the Administrative Procedure Act.” Sweet v. Sheahan, 235 F.3d 80, 90 (2d Cir.
2000). Generally speaking, “[r]etroactivity is not favored in the law.” City of New
York v. Permanent Mission of India to the United Nations, 618 F.3d 172, 192 (2d Cir.
2010) (quoting Sweet, 235 F.3d at 89). This is because retroactivity creates
unfairness by upending “legitimate expectations and upset[ting] settled
transactions.” Rock of Ages Corp. v. Sec’y of Lab., 170 F.3d 148, 158 (2d Cir. 1999);
see also Barenboim v. Starbucks Corp., 698 F.3d 104, 113 (2d Cir. 2012) (suggesting
that a regulation would “raise a retroactivity concern” where it “attach[ed] new
penalties or other legal consequences to actions preceding [its] promulgation”).
However, these reasons do not apply with the same force to interpretive rules,
which merely explain the meaning of an ambiguous statute. Blake v. Carbone, 489
F.3d 88, 98–99 (2d Cir. 2007); see also Barenboim, 698 F.3d at 113 (suggesting that a
distinction exists between legislative and interpretive rules for purposes of
35
retroactivity because an interpretive rule merely “clarif[ies] the meaning of an
ambiguous statute”).
A legislative rule “‘grants rights, imposes obligations, or produces other
significant effects on private interests,’” while an interpretive rule is an agency’s
“‘intended course of action, its tentative view of the meaning of a particular
statutory term, or internal house-keeping measures organizing agency
activities.’” White v. Shalala, 7 F.3d 296, 303 (2d Cir. 1993) (quoting Perales v.
Sullivan, 948 F.2d 1348, 1354 (2d Cir. 1991)). “The central question is essentially
whether an agency is exercising its rule-making power to clarify an existing
statute or regulation, or to create new law, rights, or duties in what amounts to a
legislative act.” Id.We agree with the district court that the 2015 Rule is legislative and should
not apply retroactively. The 2015 Rule “change[d] the law.” Blake, 489 F.3d at 98.
The Act is silent on whether the family out-of-pocket limit or individual out-of-
pocket limit should apply to an individual covered by a family plan. See 42
U.S.C. § 18022(c)(1)(B). “The extent and nature of the ambiguities” in the ACA on
this topic suggest “that the statute itself does not create [embedded cost-sharing
requirements] and reinforce the conclusion that the [2015 Rule is] legislative.”
36
Sweet, 235 F.3d at 92; see also Chamber of Com. v. OSHA, 636 F.2d 464, 469 (D.C.
Cir. 1980) (“Congress has not legislated and indicated its will on th[is]
question . . . therefore the Administration must have done more than exercise its
power to fill up the details.” (internal quotation marks omitted)). It follows, then,
that before the 2015 Rule was issued, insurers regularly required individuals on
family plans to meet the family out-of-pocket limit. See 80 Fed. Reg. at 10,824–25
(acknowledging that this “clarification” would effectively alter the types of
health insurance policies that insurers are permitted to offer). Furthermore,
before the 2015 Rule was promulgated, no federal agency or court read the Act’s
cost-sharing provision to require embedded cost-sharing.
Additionally, the actions of HHS and other agencies demonstrate that the
2015 Rule was legislative. First, the rule was enacted through the notice-and-
comment process. Compare Patient Protection & Affordable Care Act; HHS
Notice of Benefits & Payment Parameters for 2016, 79 Fed. Reg. 70,674, 70,723
(Nov. 26, 2014), with 80 Fed. Reg. at 10,824 (“We sought comments on these
proposed requirements and clarifications as well as whether other requirements
and clarifications were needed.”). The notice-and-comment process is typically
reserved for legislative rules. See Gonnella v. United States Sec. & Exch. Comm’n,
37
954 F.3d 536, 546-47 (2d Cir. 2020) (“Such ‘legislative rules,’ which must go
through Notice and Comment procedures, have ‘legal effect.’”) (quoting Sweet,
235 F.3d at 91)); Sweet, 235 F.3d at 93 (“Had the agencies been engaged in
interpretive rulemaking, they would have been exempt from the notice-and-
comment provisions.”).
Second, HHS indicated that the rule should be enforced only
prospectively. See 80 Fed. Reg. at 10,825 (“We note that 2016 plans must comply
with this policy.”). Providing that the rule should only be enforced prospectively
indicates that the 2015 Rule changes the existing legal landscape and requires a
phase-in period to allow market participants time to reorient their relationships.
Cf. Sweet, 235 F.3d at 92 (acknowledging that when Congress requires a delay
between the time regulations are promulgated and when they become effective,
it is because Congress “anticipate[s] that the agenc[y] w[ill] institute new legal
obligations—that the agenc[y] w[ill] engage in legislative rulemaking”). If the
agencies believed that the text of the ACA required the 2015 Rule’s
interpretation, they likely would have said so. Instead, the agencies explicitly
chose to defer the rule’s implementation, which suggests the agencies did not
believe the ACA’s operation rested on the 2015 Rule’s interpretation. As the
38
district court (Woods, J.) determined: “The 2015 Rule says that pre-2016 plans
need not comply with its interpretation. But Fisher argues that aggrieved
consumers were permitted to sue based on the same interpretation. That is an
odd result. If the Departments intended to open the door to private lawsuits
based on their interpretation, they probably would have said something to that
effect. But they did not. Indeed, Fisher has pointed to nothing in the 2015 Rule or
elsewhere to support her interpretation.” Fisher II, 478 F. Supp. 3d at 498-99
(emphasis in original).
Fisher argues that the 2015 Rule itself declares it was a “clarification” so it
must be interpretive. We regularly defer to an agency’s views on whether its
rules are legislative or interpretive. See Huberman v. Perales, 884 F.2d 62, 67 (2d
Cir. 1989) (“It is of course true that courts should give weight to an agency's
interpretation of the statutes it administers.”). But we are not obligated to abide
by an agency’s classification of its rule. See, e.g., id. at 68 (“We need not defer to
the Secretary's interpretation, therefore, as the conclusions we reach tilt us
strongly in the other direction.”).
For the foregoing reasons, we conclude the 2015 Rule is legislative and
therefore does not apply retroactively. In this case, that means the out-of-pocket
39
limit for plans in effect before 2016 should be governed by the terms of the
policy, not the 2015 Rule. Part IV.4 of the 2014 health insurance plan (the “2014
Policy”) provides:
When You have met Your In-Network Out-of-Pocket Limit in
payment of In-Network Deductibles, Copayments, and Coinsurance
for a Plan Year in the Schedule of Benefits in section XIV of this
Certificate, We will provide coverage for 100% of the Allowed
Amount for Covered in-network Services for the remainder of that
Plan Year. If other than Individual coverage applies, when members
of the same family covered under this Certificate have collectively
met the family In-Network Out-of-Pocket Limit in payment of In-
Network Deductibles, Copayments and Coinsurance for a Plan Year
in the Schedule of Benefits, We will provide coverage for 100% of the
Allowed Amount for the rest of that Plan Year. 7
No. 20-3148, App’x at 305. A straightforward reading of the 2014 Policy indicates
that the family out-of-pocket limit applies to an individual on a family plan. 8 The
third sentence of Section IV.4 of the 2014 Policy provides specifically that “[i]f
other than individual coverage”—that is, family coverage—“applies,” the out-of-
pocket limit is met when the family limit is “collectively” satisfied by the family’s
medical expenses. There is no dispute that Fisher, the spouse of a D&S partner,
7 Similar language is present in the 2015 health insurance plan (“2015 Policy”), so
our analysis applies to both plans. No. 20-3804, App’x at 47.
8 Fisher does not contest this reading of the 2014 Policy or 2015 Policy on appeal.
40
was covered as a family member by the 2014 Policy. Therefore, the family out-of-
pocket limit applies to Fisher’s reimbursement requests. See Lockheed Martin Corp.
v. Retail Holdings, N.V., 639 F.3d 63, 69 (2d Cir. 2011) (“When an agreement is
unambiguous on its face, it must be enforced according to the plain meaning of
its terms.”).
Fisher’s arguments regarding the out-of-pocket limit are unpersuasive.
First, Fisher argues that it was error for the district court (Sullivan, J.) to consider
whether the 2015 Rule should apply retroactively because Fisher asserts rights
under the ACA, not any administrative action. Putting aside the fact that Fisher
raised the 2015 Rule below in the first instance, it is clearly not error for a federal
court to consider the agency interpretation of a statute it administers in order to
determine how to apply the statute. See Chevron, U.S.A., Inc. v. Nat. Res. Def.
Council, Inc., 467 U.S. 837, 844 (1984) (“We have long recognized that
considerable weight should be accorded to an executive department's
construction of a statutory scheme it is entrusted to administer.”).
Second, Fisher argues that the text, structure, and legislative history of the
ACA demonstrate that the individual out-of-pocket limit applies to individuals
enrolled in a family plan. On the text, she argues that Section 18022(c)(1)(A),
41
which states that “[t]he cost-sharing incurred under a health plan with respect to
self-only coverage or coverage other than self-only coverage for a plan year
beginning in 2014 shall not exceed the dollar amounts in effect under section
223(c)(2)(A)(ii) of title 26 for self-only and family coverage, respectively, for
taxable years beginning in 2014,” implies that Congress intended that the out-of-
pocket limit for an individual should not exceed either of the amounts set forth
in 26 U.S.C. § 223(c). Section 223(c) sets forth the out-of-pocket limits for
individuals on self-only coverage ($5,000) and family coverage (twice the self-
only coverage amount). 9 Fisher places too much emphasis on the use of
“amounts” rather than “amount” in Section 18022(c). An equally, if not more
likely, interpretation would be that the word “respectively” indicates that the
plural “amounts” refers to the thresholds established for individuals on self-only
plans versus family plans, meaning that the out-of-pocket limit for those on self-
only coverage should not exceed the limit for individuals on self-only coverage
in Section 223(c) and that individuals on family plans should not exceed the
9These amounts are indexed to the rate of medical inflation. See 42 U.S.C. §
18022(c)(4).
42
limits for family coverage in Section 223(c). In any event, the ACA is ambiguous
on this point as discussed above. See Majority Op. at 33.
On the structure and purpose of the ACA, Fisher argues that the ACA
extends greater insurance benefits to families so Section 18022(c) must do the
same. But Section 18022(c) already provides greater insurance benefits to families
by placing a statutory cap on family out-of-pocket limits. 42 U.S.C. §
18022(c)(1)(A) (“The cost-sharing incurred under a health plan with respect to
self-only coverage or coverage other than self-only coverage for a plan year
beginning in 2014 shall not exceed the dollar amounts in effect . . . .”). This
section fulfills the ACA’s purpose of extending greater insurance benefits to
families without clearly indicating that the individual out-of-pocket limit should
apply to an individual on a family plan.
For the foregoing reasons, we affirm the district court’s holding that the
ACA does not provide that the annual limitation on cost sharing for self-only
coverage applies to all individuals regardless of whether the individual is
covered under a self-only plan or is covered by an individual or family plan for
plans in effect prior to 2016.
V. Cost Differential Under the Affordable Care Act
43
Fisher also argued that the Choose Generic cost differential (“Cost
Differential”) should count toward her out-of-pocket limit in her claims
regarding the 2014 and 2015 plans. 10 In Fisher I, the court (Woods, J.) held that
Aetna’s decision that the Cost Differential did not count toward Fisher’s out-of-
pocket limit was not arbitrary and capricious. Fisher I, 2020 WL 2792994, at *13.
Fisher then argued in her motion for summary judgment that the ACA requires
cost-sharing provisions, such as the Cost Differential, to count toward her out-of-
pocket limit. The district court (Woods, J.) again rejected this argument in Fisher
II, holding that Fisher’s EffexorXR was “not a covered service.” Fisher II, 478 F.
Supp. 3d at 499.
On appeal, Fisher argues that under the ACA, the Cost Differential must
count toward her out-of-pocket-limit. She argues the Cost Differential is “cost-
sharing” under the terms of the Act and that EffexorXR was a covered service.
Aetna responds that the Cost Differential was not a “covered service”
under the health insurance plans, and, besides, Fisher did not exhaust her out-of-
10In Fisher III, the district court (Sullivan, J.) did not reach this issue because it
found that Fisher did not meet her out-of-pocket limit. Fisher III, 2019 U.S. Dist.
LEXIS 233798, at *20.
44
pocket limit for 2014. As for the 2015 plan, Aetna argues that Fisher waived this
argument because she never presented this argument to Aetna in her 2015
administrative appeal.
The Choose Generic clause of the 2014 Policy and 2015 Policy states: “An
additional charge may apply when a Prescription Drug on a higher tier is
dispensed at Your or Your Provider’s request, when a chemically equivalent
Prescription Drug is available on a lower tier unless We approve coverage at the
higher tier. You will have to pay the difference between the cost of the
Prescription Drug on the higher tier and the cost of the Prescription Drug on the
lower tier.” No. 21-1, App’x at 116 (emphasis added). 11
The ACA states:
(3) Cost-sharing. In this title—
(A) In general
The term ‘cost-sharing’ includes—
(i) deductibles, coinsurance, copayments, or similar charges; and
(ii) any other expenditure required of an insured individual which is
a qualified medical expense (within the meaning of section 223(d)(2)
of Title 26) with respect to essential health benefits covered under
the plan.
(B) Exceptions
Such term does not include premiums, balance billing amounts for non-
network providers, or spending for non-covered services.
11 The 2015 health insurance plan has an equivalent Choose Generic clause.
45
42 U.S.C. § 18022(c)(3).
The issue is whether the Cost Differential falls under the exception to
Section § 18022(c)(3)(B) “as spending for non-covered services.” We hold that
under the terms of the 2014 and 2015 Policy and the ACA, the Cost Differential
does not count toward Fisher’s out-of-pocket limit.
To qualify as a “Covered Service[]” under the 2014 or 2015 Policy, the
service must be “medically necessary.” No. 20-3804, App’x at 41. A service is
“medically necessary” if, among other things, (1) it is “not primarily for the
convenience of You, Your family, or Your Provider,” and (2) it is “not more
costly than an alternative service or sequence of services, that is at least as likely
to produce equivalent therapeutic or diagnostic results.” No. 20-3804, App’x at
46.
Aetna directly communicated to Dunnegan that Fisher could seek a
medical-necessity waiver of the Choose Generic provision which would allow
Aetna to cover the EffexorXR and only charge Fisher for the copay. No. 20-3148,
App’x at 394-95, 414. However, Fisher “never sought a medical-necessity
waiver.” Fisher I, 2020 WL 2792994, at *13. Dunnegan faxed Dr. Rosenfeld on
August 19, 2014, requesting he call Aetna and discuss whether they could pay for
46
EffexorXR. But on August 21, Dunnegan changed his mind and directed Dr.
Rosenfeld not to request a waiver. As the district court (Woods, J.) concluded,
“[t]hat decision is explicable only by reference to Dunnegan’s interest in
converting an administrative hassle into a potentially lucrative class-action
lawsuit, with his [w]ife as lead plaintiff and his firm as plaintiff’s counsel.” Fisher
I, 2020 WL 2792994, at *13.
Here, Fisher repeats the same argument she made below that her
EffexorXR prescription was a covered service because Dr. Rosenfeld, in a sworn
statement, stated that EffexorXR was medically necessary for Fisher. However,
Dr. Rosenfeld “did not certify EffexorXR was medically necessary in the relevant
sense; that is, he did not certify that EffexorXR was medically necessary relative
to the venlafaxine.” Fisher I, 2020 WL 2792994, at *12. Because Fisher failed to
apply for and obtain a medical-necessity waiver, EffexorXR could not be
considered medically necessary and therefore, could not qualify as a “covered
service” under the policy. Accordingly, the Cost Differential falls under the
exceptions to cost-sharing in Section 18022(c)(3)(B) and does not count toward
Fisher’s out-of-pocket limit.
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Fisher makes the same argument in her appeal regarding her 2015 Policy.
In Fisher III, the district court (Sullivan, J.) held that Fisher did not exhaust her
out-of-pocket limit for 2015 so it did not reach the issue. Fisher III, 2019 U.S. Dist.
LEXIS 233798, at *20 (“Since there is no dispute that [Fisher’s] expenditures did
not exceed the out-of-pocket limit for her family plan in 2015, the Court need not
decide whether Aetna approved EffexorXR as medically necessary in 2015.”).
Fisher does not dispute this on appeal. Therefore, we need not determine
whether Aetna approved EffexorXR as medically necessary in 2015 and the
district court’s (Sullivan, J.) judgment in favor of Aetna on this issue is affirmed.
CONCLUSION
For the foregoing reasons, we affirm the various judgments of the two
district courts.
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