Lyn M. v. Premera Blue Cross and Microsoft Corporation Welfare Plan (U.S. Dist. Ct. for the Dist. of UT, case no. 2:17-cv-01152-BSJ, Nov 30, 2021). In this ruling, Judge Bruce Jenkins granted Plaintiffs’ motion for Summary Judgment based on an ERISA Recovery of Benefit 1132(a)(1)(B) action and asked Plaintiffs to prepare a form calculating the amounts due. Plaintiffs’ dependent, LM, suffered from several mental health disorders including depression, anxiety and suicidal ideation, stayed 14 months in an RTC. Most of her care was denied and costs of the stay exceeded $80,000. The initial denial was made because LM was only evaluated by a psychiatrist once a month but the plan required evaluation once a week. The denial was upheld for both the internal and external appeal review process. In part, the denial was subsequently based on the opinion that LM did not exhibit ongoing suicidal or homicidal ideation or risk of self-harm sufficient to justify around-the-clock residential care.
Originally, the Court had granted summary judgement to Premera applying the arbitrary and capricious standard of review. But the Tenth Circuit reverse noting two errors in Lyn M. v. Premera Blue Cross, 966 F.3d. 1061 (10th Cir. 2020). First the correct standard of review was ruled to be de novo in part because Premera had failed to disclose the plan instrument (rather than just disclosing the summary plan description); and secondly, medical necessity must be based on both the Summary Plan Description and Premera’s Behavioral Health medical policy (the latter of which the plan failed to properly reference). Judge Jenkins criticized the plan for switching the rationale for making the denial during the appeals process related to the “intensity of service” rationale. In addition, the plan gave instructions to its reviewers not to rely on the Behavioral Health medical policy when conducting their review and one of the reviewers also ignored the evidence of suicidal ideation. Because of these and other factors, the court ruled that “Plaintiffs have provided sufficient evidence to show that, by a preponderance of the evidence, they are entitled to benefits under the Summary Plan Description and the Medical Policy”