- Filing. Published in U.S. District Court for the Southern District of Ohio, Western Division on November 30, 2020 (Case no. 1:18-cv-300).
- Background. Plaintiff suffered for years with depression, anxiety, eating disorders, suicide ideations and drug use. Plaintiff sued Defendant health plan for denial of benefits for medically necessary care at both a licensed therapeutic Wilderness Therapy and RTC programs based on four legal counts. Three of the four counts were dismissed in 2019. The remainder addressed an ERISA recovery of benefits action pursuant to § 1132 (a)(1)(B). The issue before the Court is whether the Defendant’s determination at the RTC was not medically necessary was arbitrary and capricious?
- Holding. Judge Timothy S. Black granted Defendant’s motion to dismiss.
- Analysis. In supporting the motion to dismiss, the court noted that the Plaintiff was making progress in their treatment. The Defendant Anthem’s:
determination was not arbitrary and capricious because Anthem was relying on the medical opinions of A.G.’s providers….When a plan administrator chooses to rely upon the medical opinion of one doctor over that of another in determining whether a claimant is entitled to ERISA benefits, this decision cannot be said to have been arbitrary and capricious because it would be possible to offer a reasoned explanation, based upon the evidence, for the plan administrator’s decision.
The judge noted that based on substantial evidence in the record that the Plaintiff could be treated at a lower level of care in part because his condition was not deteriorating.