Medical Benefit Claims

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This week’s first notable decision, Meyers v. Kaiser Found. Health Plan, Inc., No. 19-15051, __F.App’x__, 2020 WL 1673078 (9th Cir. Apr. 6, 2020), is a cautionary tale for claimants seeking out-of-network treatment under a Kaiser health plan. Meyers brought the action on behalf of her teenage daughter, A.M., a covered dependent under the Kaiser medical plan. Meyers sought reimbursement of medical expense for A.M.’s treatment at Elevations residential treatment center for approximately four months in 2016. 

District Court Judge Lucy Koh granted judgment for Kaiser following a bench trial. Meyers appealed.

While the parties disputed the standard of review, the Ninth Circuit agreed with the district court— even under de novo review, Kaiser’s denial was proper. 
Continue Reading Ninth Circuit Holds Kaiser Not Liable for Out-of-Network Mental Health Treatment Benefits

This week’s notable decision is Bain v. United Healthcare Inc., No. 15-CV-03305-EMC (N.D. Cal. Feb. 15, 2020), a case involving a dispute over residential treatment benefits.  What’s notable about this decision, and a couple of other decisions picked up this past week, is the reverberation of the groundbreaking decision in Wit v. United Behavioral Health, No. 14-CV-02346-JCS, 2019 WL 1033730 (N.D. Cal. Mar. 5, 2019).
Continue Reading Court Finds Collateral Estoppel Applies to Wit v. UBH Decision on Issue of Conflict of Interest in Residential Treatment Dispute

This week’s notable decision is another terrible decision for ERISA plan participants out of the Fifth Circuit Court of Appeals:  Ariana M. v. Humana Health Plan of Texas, Inc., No. 18-20700, __F.App’x__, 2019 WL 5866677 (5th Cir. Nov. 8, 2019) (“Ariana II”).  This is a disappointing sequel in a case where the Fifth Circuit previously issued a plaintiff-friendly decision on the standard of review applied in ERISA cases.  The case first reached the Fifth Circuit in Ariana M. v. Humana Health Plan of Texas, Inc., 884 F.3d 246 (5th Cir. 2018) (“Ariana I”) in which the court issued an en banc published decision overturning the longstanding position on standard of review in Pierre v. Conn. Gen. Life Ins. Co., 932 F.2d 1552, 1562 (5th Cir. 1991).  The court reversed and remanded the case to the district court for review under a de novo standard of review. (Read more about Ariana I in Brent Dorian Brehm’s Fall 2017 EBC Newsletter article: What Does de novo Review Mean Under ERISA?)
Continue Reading Fifth Circuit Denies Attorneys’ Fees to Plaintiff for en banc Success Changing Judicial Standard of Review