Medical Benefit Claims

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For those of us waiting for a court to follow the reasoning in the remarkable Wit v. United Behavioral Health, 2019 WL 1033730 (N.D. Cal. Mar. 5 2019) decision earlier this year, we got it last week with the decision in S.B. v. Oxford Health Ins., Inc., No. 3:17-CV-1485 (MPS), __F.Supp.3d__, 2019 WL 5726901 (D. Conn. Nov. 5, 2019). In sum, Judge Michael Shea found that Oxford’s denial of a 16-year-old’s residential treatment for an eating disorder was arbitrary and capricious and remanded to Oxford for further consideration. 

To start, the court did not accept Plaintiff’s argument that a de novo standard of review should apply because United Behavioral Health Services, Inc. (“UBH”), not Oxford, made the benefit determination. Plaintiff contended that although UBH made the benefit determination, there is no indication that the Plan gives UBH discretionary authority. The court found that the Plan language contemplates the delegation of authority to third parties with the definition of “Us, We, Our” which included not only Oxford but also anyone to whom Oxford “legally delegate[s] performance,” including UBH. 
Continue Reading District Court Finds Oxford’s Denial of Teen’s Residential Treatment Arbitrary and Capricious Due to Reliance on UBH Guidelines

Finally!  A win for employees on the promise to provide lifetime healthcare benefits.  This week’s notable decision is a reported decision out of the Northern District of Illinois, Stone v. Signode Indus. Grp., LLC, No. 17 C 5360, __F.Supp.3d__, 2019 WL 1146829 (N.D. Ill. Mar. 13, 2019).  

In Stone, Plaintiffs, a labor union and two former employees, sought to enforce healthcare benefits under a collective bargaining agreement (“CBA”) which Defendant gave notice of termination in 2015.  The CBA contains the following provisions:

Any Pensioner or individual receiving a Surviving Spouse’s benefit who shall become covered by the Program established by the Agreement shall not have such coverage terminated or reduced (except as provided in this Program) so long as the individual remains retired from the Company or receives a Surviving Spouse’s benefit, notwithstanding the expiration of this Agreement, except as the Company and the Union may agree otherwise. [Section 6]
Continue Reading Court Rules Collective Bargaining Agreement Provides Vested Lifetime Benefits

Hello, ERISA Watchers!  Last week was quite the busy week for ERISA decisions.  By now, you all should have gotten wind of the over 40,000-word findings of fact and conclusions of law issued in Wit v. United Behavioral Health, No. 14-CV-02346-JCS, 2019 WL 1033730 (N.D. Cal. Mar. 5, 2019), where Magistrate Judge Joseph C. Spero essentially found that UBH’s Guidelines for treatment of mental health and substance use disorders are largely inconsistent with generally accepted standards of care.  A “summary” of that decision would take several pages (and my entire precious weekend) so I picked another less-publicized decision to highlight for you today:  International Union, United Automobile, Aerospace And Agricultural Implement Workers of America (UAW), et al., v. TRW Automotive U.S. LLC, No. 18-1160, __F.App’x__, 2019 WL 1040636 (6th Cir. Mar. 5, 2019).

In International Union, TRW Automotive brought a combined appeal challenging an arbitral decision in favor of retired TRW employees and their union and challenging the district court’s denial of TRW’s motion to rule that attorney’s fees could not be awarded against it.  
Continue Reading Sixth Circuit Vacates Arbitrator’s Award of Enhanced Healthcare Coverage to Retirees