CBCA 7357

DENIED: May 21, 2025 CBCA 7357 UNITEDHEALTHCARE INSURANCE COMPANY, INC., Appellant, v. OFFICE OF PERSONNEL MANAGEMENT, Respondent. Stephen J. McBrady, Charles Baek, Payal Nanavati, and Issac D. Schabes of Crowell & Moring LLP, Washington, DC, counsel for Appellant. Emily Warner, Nicole M. Lohr, Matthew J. Ruane, and Beth M. Stratton, Office of the General Counsel, Office of Personnel Management, Washington, DC, counsel for Respondent. Before Board Judges RUSSELL, KULLBERG, and VOLK. VOLK, Board Judge. Appellant, UnitedHealthcare Insurance Company, Inc. (UnitedHealth), contracts with respondent, the Office of Personnel Management (OPM), to offer health insurance plans to federal employees through the Federal Employees Health Benefits (FEHB) program. In 2020, UnitedHealth paid claims totaling $3,838,510.70 for a heart transplant procedure for the dependent son of a federal employee who had enrolled in a UnitedHealth FEHB plan. After the procedure, but before paying the claims, UnitedHealth processed a retroactive disenrollment of the employee from its insurance plan. The Government then retroactively reenrolled the employee, and UnitedHealth paid the claims. CBCA 7357 2 UnitedHealth seeks to recover the $3,838,510.70 that it paid for the procedure, claiming that OPM breached the parties’ FEHB contract. UnitedHealth originally asserted that the retroactive reenrollment was improper, but it is no longer pursuing that theory. Instead, it now argues that the Government breached the contract by providing erroneous information regarding the employee’s FEHB eligibility status in 2019, the year before the procedure. Although the parties agree that the employee would have been eligible to enroll in UnitedHealth’s plan for 2020, the year during which the transplant procedure occurred, UnitedHealth avers that, absent the Government’s error in 2019, it would have disenrolled the employee sooner and there is a “reasonable possibility” that the employee subsequently would have selected a different insurance plan. The parties have cross-moved for summary judgment. We grant OPM’s motion. Background I. Enrollment in UnitedHealth’s Plan In 2015, OPM and UnitedHealth entered into contract no. CS 2945. Under that contract, including modifications thereto, UnitedHealth offered its “Choice Plus Advanced” health insurance plan to federal employees under the FEHB program at all times relevant to this appeal. An Internal Revenue Service (IRS) employee, whom the parties refer to as “CM,” enrolled her family in that plan during the open season preceding the 2019 plan year. At that time, she was on leave without pay (LWOP). By February 2, 2019, CM had been on leave without pay from the IRS for 365 days. By regulation, an employee who has been on leave without pay for 365 days becomes ineligible for FEHB coverage. 5 CFR 890.303(e) (2019). On February 6, 2019, the IRS executed a Standard Form 2810 (SF-2810), Notice of Change in Health Benefits Enrollment, indicating that CM’s enrollment was to terminate effective February 2, 2019. UnitedHealth received the information contained in this SF-2810 via a weekly electronic transmission from OPM on February 10, 2019. Complaint ¶ 32; Oral Argument Transcript at 8. OPM asserts that UnitedHealth was required to disenroll CM from its plan upon receiving this information. Respondent’s Motion for Summary Judgment at 9; see also Complaint ¶ 17 (“The SF-2810 form serves as a notice that the carrier should process the termination of an enrollee.”). UnitedHealth did not disenroll CM from its plan, or take any other immediate action, upon receiving the SF-2810 in February 2019. Consequently, a discrepancy began appearing in quarterly reconciliation reports produced by an FEHB electronic system known as the Centralized Enrollment Reconciliation Clearinghouse System (CLER). FEHB carriers, CBCA 7357 3 including UnitedHealth, submit their enrollment information in CLER each quarter. If the carrier’s enrollment information does not match that of the Government’s payroll office1 for an enrollee, CLER generates an error code for that enrollee in its quarterly report. For CM, a March 4, 2019, quarterly CLER report generated the following discrepancy: “160 - Enrollee on Carrier Record But No Payroll Office Record Found.” Exhibit 51a.2 CLER includes fields in which both the Government’s payroll office and the insurance carrier can enter narrative comments.