Scott M. v. Blue Cross & Blue Shield of Mass.

Scott M. v. Blue Cross & Blue Shield of Mass. (U.S. Dist. Ct. for the Dist. of UT, case no. 1:17-cv-00009,  March 24, 2021).  Judge Clark Waddoup dismissed Defendant’s summary judgement motion relating to Plaintiff’s claim for RTC benefits.  Regarding Plaintiff who suffered from MH and SUD conditions, the Judge ruled that Defendant violated ERISA procedural requirements because the Plan failed to consider Plaintiff’s SUD conditions (using InterQual criteria) and failed to factor in the sub-acute setting for the MH conditions.  Judge Waddoup used a de novo standard of review when remanding the claim for benefits to the plan for re-consideration.  Among other deficiencies, the plan failed to consider the entire record during initial denial and the appeals process, which included the omission of a psychiatric evaluation regarding Plaintiff’s high risk of suicide.  Decision was based on an § 502(a)(1)B) claim [and the Court did not consider the § 502(a)(3) claim].  Attorney fees were awarded but Court is waiting on whether to award “prejudgment interest” until the remand.