Court Overturns Benefit Denial Due to Plan’s Improper Application of Experimental Exclusion

Posted August 14, 2013 by Megan DiMartino in News | 0 comments


This decision replaces an earlier decision that upheld a self-insured health plan’s denial of benefits for a participant’s surgical procedure because the plan language clearly excluded the procedure as experimental. But after learning that the language actually came from the claims administrator’s internal policy document (not the plan itself), the court vacated its earlier decision and reconsidered the administrative record. The court reviewed the benefit denial “de novo” (anew), rather than applying a deferential standard of review, because the committee that made the final decision was not the ERISA plan administrator and had not been delegated discretionary authority.

The court’s review focused on the plan provision excluding experimental and investigational treatments because the plan’s claim denial letter and two appeal denial letters had not challenged medical necessity. The court concluded that the plan’s claim denial letter and first-level appeal denial letter both relied solely on language excerpted from the claims administrator’s internal policy document stating that the requested procedure is experimental or unproven—copied verbatim each time, without any explanation of how it applied to the participant’s situation. And the second-level appeal denial letter similarly repeated the same rationale in reliance on the earlier letters. In particular, none of the denial letters responded to (or even acknowledged receipt of) detailed information provided by the participant’s doctor regarding the procedure’s repeated use, safety, and efficacy for treating patients with the participant’s diagnosis. (The court also noted a number of other procedural improprieties, including inconsistencies between decisionmakers’ internal notes and the denial letters and confusion over whether the participant had been offered or received an external review.) Ultimately, the court concluded that bare reliance on the claims administrator’s internal policy determination was not sufficient to demonstrate that the experimental exclusion applied, and ruled that the participant is entitled to benefits.

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