When is a hospital not a hospital? The Fifth Circuit provided an answer in a July 29 decision in favor of a nurse seeking insurance coverage for medical treatment at a residential treatment facility.
Rebecca was a nurse at North Cypress Medical Center, in Texas. Back in 2011 she was treated for an eating disorder at Timberline Knolls Residential Treatment Center, in Illinois. When she sought reimbursement under the North Cypress health insurance plan, her claim was denied because she hadn’t received “prior authorization” by the North Cypress HR department—something the plan required for treatment at a “hospital,” defined as a facility licensed by the state as a psychiatric hospital or residential treatment facility.
When Rebecca sued North Cypress in federal court, North Cypress moved for summary judgment, arguing that because Timberline Knolls was a “hospital” under the plan provision, her failure to secure prior authorization meant her care wasn’t covered. The court agreed and gave North Cypress summary judgment.
Rebecca appealed to the Fifth Circuit. That court reversed the decision in favor of North Cypress and ordered the district court to enter judgment in favor of Rebecca. Why? Because even though Timberline Knolls might well be a hospital, North Cypress had put nothing in the record to support that conclusion. The court observed that its decision might have been different if North Cypress had simply submitted an affidavit stating that Timberline Knolls was a hospital, but that hadn’t happened.
So the answer to the question is that a hospital isn’t a hospital if there’s nothing in the court record confirming that it is.
The case is Hamsher v. North Cypress Med. Center, No. 14-20576 (5th Cir. 2015).
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