## Facts

- Christopher Muratore, a federal employee, enrolled his family in a PCA Health Plans of Florida HMO offered under the Federal Employees Health Benefits Act (FEHBA).
- The plan’s medical-benefits section covered “rehabilitative therapy, including speech therapy,” but limited coverage to “up to two months” and excluded long-term rehabilitative therapy.
- The plan’s mental-conditions section covered psychiatric treatment, including “individual therapy,” as necessary for treatment of mental illness or disorders.
- The Muratores’ daughter, Kassandra, was diagnosed with autism, which the parties treated as a mental disorder under the plan.
- A psychiatrist prescribed speech therapy as part of Kassandra’s autism treatment; PCA paid for roughly two months and then denied further coverage under the rehabilitative-therapy limitation.
- The Muratores appealed internally to PCA and then to the Office of Personnel Management (OPM); OPM affirmed the denial as consistent with the plan’s two-month cap for speech therapy.
- The Muratores paid for continued therapy and sued, seeking reimbursement and attorneys’ fees under the Equal Access to Justice Act (EAJA).
- The district court ordered reimbursement (summary judgment for the Muratores) but denied EAJA fees; OPM appealed the merits, and the Muratores cross-appealed the fee denial.

## Issues

1. Whether OPM acted arbitrarily and capriciously under FEHBA by interpreting the plan to treat speech therapy for autism as rehabilitative therapy subject to a two-month cap, rather than as unlimited “individual therapy” under the mental-conditions provision.
2. Whether the Muratores were entitled to attorneys’ fees under EAJA on the ground that OPM’s position was not substantially justified.

## Decision

- The Eleventh Circuit reversed the district court’s judgment requiring reimbursement for speech-therapy expenses beyond the two-month limit.
- The court held that OPM’s interpretation of the plan was reasonable and therefore not arbitrary or capricious.
- The Eleventh Circuit affirmed the denial of EAJA attorneys’ fees because OPM’s position was substantially justified.
- The case was remanded for entry of judgment in favor of OPM.

## Legal Principles

- A court reviewing OPM’s FEHBA benefits determination applies a deferential arbitrary-and-capricious standard and upholds OPM’s plan interpretation if reasonable and consistent with plan text and structure.
- Specific plan language governing a treatment modality (e.g., “rehabilitative therapy, including speech therapy,” with a time cap) controls over more general mental-health treatment provisions absent clear language overriding the limitation.
- Classification of a condition as a mental disorder does not require that every service used to treat it be covered under the mental-conditions benefits section when the plan separately categorizes and limits certain services.
- Under EAJA, fees are unavailable when the government’s position has a reasonable basis in law and fact (is substantially justified), even if the claimant obtained relief in the district court.

## Conclusion

The Eleventh Circuit held that OPM reasonably construed the FEHBA plan to limit coverage for speech therapy to a two-month rehabilitative-therapy cap, even when prescribed to treat autism, and it denied EAJA fees because OPM’s position was substantially justified.


Muratore v. U.S. Office of Pers. Mgmt., 222 F.3d 918 (11th Cir. 2000)