“In deciding whether a fiduciary abused its discretion in denying ERISA benefits, this Court is bound give “due consideration” 1) to whether administrator’s interpretation is consistent with the goals of the plan; 2) whether it might render some language in the plan meaningless or internally inconsistent; 3) whether the challenged interpretation is at odds with the procedural and substantive requirements of ERISA itself; 4) whether the provisions at issue have been applied consistently; 5) and, of course, whether the fiduciaries’ interpretation is contrary to the clear language of the plan. Lockhart v. UMW 1974 Pension Trust, 5 F.3d 74, 77 (4th Cir. 1993). The Court will consider each of the factors in turn.
First, the Court finds the administrator’s interpretation to be antithetical to the goals of the plan. Plaintiff suffers extreme emotional and physical conditions that, according to the evidence in the case, would likely be alleviated as a result of this surgery. The decision to deny the relief requested is patently offensive to the plan’s goal to provide for health benefits.
Second, the denial of Plaintiffs claim renders the plain language of the plan meaningless. The plan provides that weight loss generally is excluded “when an underlying severe medical condition is not present.” The plan goes on to state, however, that “severe medical conditions include, but are not limited to: diabetes, hypertension, cardiovascular disease, etc.” The record establishes that Plaintiff suffers from several severe medical conditions, including hypertension. Thus, to the extent that CIGNA relies on this language in its denial of Plaintiff’s claim, such reliance renders the exception useless.
Third, the interpretation made by CIGNA is inconsistent with the requirements of ERISA. See 29 C.F.R. § 2560.503-1. In lieu of stating consistent reasons for the denial, each of CIGNA’s letters presented Plaintiff with at least one additional reason for her denial-and apparently one more hurdle that she would have to overcome-before CIGNA would find gastric bypass surgery appropriate.
For instance, in letter one, CIGNA stated that “there is no documentation that in the prior 12 moths, [Plaintiff] has been reasonably compliant with a supervised diet for 26 weeks.” In letter two, however, the bar was lifted. In that letter, CIGNA states that Plaintiff should have “participated in [not one, but] 2 professionally supervised weight loss programs, with reasonable compliance, of 26 weeks duration . . .” Finally, letter three adds yet another requirement. According to CIGNA, Plaintiffs weight loss program must include regular weigh-ins.
Even if the Court were to find that CIGNA complied with the procedural guidelines for ERISA, however, it would not be enough for this Court to be convinced that CIGNA did not abuse its discretion in denying Plaintiff the requested benefits. Moreover, although remand might be appropriate in most instances when the administrator has failed to follow ERISA’s guidelines, the evidence is so overwhelming that CIGNA abused its discretion in this case that a remand would serve no purpose other than to cause needless delay.
Fourth, there is nothing in the record on which the Court can consider whether CIGNA has consistently applied the guidelines. Nevertheless, even if there was overwhelming evidence for the Court to find that this factor weighs in favor of Defendant, it would not be enough for this Court to find that the administrator did not abuse its discretion in denying Plaintiffs claim.
Fifth, CIGNA’s interpretation is diametrically opposed to the plain meaning of the plan. Read as a whole, it is not reasonable that, based on the evidence that was before it, Plaintiffs claim should have been denied. The opinions of four board certified doctors, who all agreed that the surgery was needed, is virtually uncontradicted. Even when the guidelines are considered, a reasonable interpretation of them leads to the same conclusion. Certainly, these doctors are in a far better position to examine and diagnose Plaintiff’s condition than those working on CIGNA’s behalf.
This Court is fully cognizant of the deferential substantial evidence standard of review applicable to the Court when it reviews an ERISA denial of benefits claim. Consistent with this deferential standard and considering the record as a whole, the Court must nevertheless ensure that the record contains some evidence beyond a mere scintilla that would allow reasonable minds to concur in the conclusion reached by the administrator. Mindful of this deferential standard, the record yields, at best, a mere scintilla of evidence to support CIGNA’s finding that Plaintiffs claim should be denied. CIGNA’s finding that Plaintiffs benefit request was not medically necessary is not reasonable. Accordingly, the Court must reverse.” (Click here to view the full decision.)
I have used the case periodically over the years to make the point that a health insurer/plan cannot deny a claim based upon criteria or guidelines that contradict or are inconsistent with the plan language in denying a claim.
This case was featured in a news story that was syndicated nationwide on the NBC News. I was quoted in the story.
