M. S. v. Premera Blue Cross (U.S. Dist. Ct. for the Dist. of Utah, case no. 2:19-cv-00199-RJS-CMR, August 10, 2021). This case is an important court ruling in terms of leveraging fines against a health plan for failure to disclose InterQual Guidelines and the administrative service agreement (ASA) between the self-funded health plan (Microsoft is the named fiduciary and plan administrator) and the claims administrator (Premera). Premera and the independent review organizations used InterQual Criteria for denying the RTC treatment for the Plaintiff’s dependent, who was experiencing a range of anxiety, development disorders, autism and other conditions. Although the Judge Robert Shelby dismissed the ERISA recovery of benefits claim [§ 1132(a)(1)(B)] based on an arbitrary and capricious standard of review, he denied Defendant’s motion to dismiss the ERISA parity claim [§1132(a)(1)].
Specifically, Judge Shelby fined Defendant $123,100 in statutory penalties plus reasonable attorney fees (to be determined) based on the Defendants three-year delay in turning over key documents to the Plaintiffs. He noted that “(t)he length of delay and number of requests also support imposition of significant statutory penalties.” In addition to the need to access the medical/surgical comparative InterQual Guidelines, the Plaintiffs argued that “the ASA is a contract essential to understanding how the Plan operates because the responsibilities of the Plan and Claim administrators are divided and each effect the family’s rights under the plan.” Judge Shelby agreed noting “the set of documents requested by the Family was discrete and important to their rights under ERISA. The ASA and InterQual Criteria each are important to put the Family ‘in a position to make informed decisions about how best to protect their rights.’”