Employee Benefits News examines legal developments that impact the employee benefits and executive compensation employers provide, including federal and state legislation, rules from federal...
Blue Cross Blue Shield of Michigan can’t escape a proposed class action challenging the way it covers treatments for adults with human growth hormone deficiencies ( Mac v. Blue Cross Blue Shield of Mich. , 2017 BL 189966, E.D. Mich., No. 2:16-cv-13532, 6/6/17 ).
The coverage criteria Blue Cross relied on to deny a man’s claims for the drug Genotropin weren’t necessarily incorporated into the man’s employer-sponsored health plan, a federal judge concluded June 6. In denying the insurer’s motion to dismiss, the judge said he wasn’t convinced that the coverage criteria—which excluded coverage for Genotropin used to treat hormone deficiencies with no known cause—had become a plan term “immune from judicial review.”
The case asks when an insurer’s coverage guidelines become incorporated into a health plan such that a benefit denial based on those guidelines can’t be challenged through a benefit claim under the Employee Retirement Income Security Act. The judge relied on a 2015 district court decision refusing to dismiss a case challenging coverage denials made by United Behavioral Health. In that case, the court declined to find that the challenged coverage guidelines had been incorporated into the relevant ERISA plans because none of the plans contained any reference to the guidelines.
Here, the judge said that coverage criteria must “reasonably interpret the plan” for a benefit denial based on the criteria to be immune from judicial review. Because the judge had “no information explaining how these coverage criteria were determined or by whom,” he allowed the case to move forward for more fact-finding.
Although the case was filed as a proposed class action, the judge declined to address the class claims at this stage of litigation.
Judge Paul D. Borman of the U.S. District Court for the Eastern District of Michigan wrote the decision.
Rossman Saxe PC and Miller Law Firm represent the man who sued for coverage. Jones Day represents Blue Cross.
To contact the reporter on this story: Jacklyn Wille in Washington at firstname.lastname@example.org
To contact the editor responsible for this story: Jo-el J. Meyer at email@example.com
Copyright © 2017 The Bureau of National Affairs, Inc. All Rights Reserved.
All Bloomberg BNA treatises are available on standing order, which ensures you will always receive the most current edition of the book or supplement of the title you have ordered from Bloomberg BNA’s book division. As soon as a new supplement or edition is published (usually annually) for a title you’ve previously purchased and requested to be placed on standing order, we’ll ship it to you to review for 30 days without any obligation. During this period, you can either (a) honor the invoice and receive a 5% discount (in addition to any other discounts you may qualify for) off the then-current price of the update, plus shipping and handling or (b) return the book(s), in which case, your invoice will be cancelled upon receipt of the book(s). Call us for a prepaid UPS label for your return. It’s as simple and easy as that. Most importantly, standing orders mean you will never have to worry about the timeliness of the information you’re relying on. And, you may discontinue standing orders at any time by contacting us at 1.800.960.1220 or by sending an email to firstname.lastname@example.org.
Put me on standing order at a 5% discount off list price of all future updates, in addition to any other discounts I may quality for. (Returnable within 30 days.)
Notify me when updates are available (No standing order will be created).
This Bloomberg BNA report is available on standing order, which ensures you will all receive the latest edition. This report is updated annually and we will send you the latest edition once it has been published. By signing up for standing order you will never have to worry about the timeliness of the information you need. And, you may discontinue standing orders at any time by contacting us at 1.800.372.1033, option 5, or by sending us an email to email@example.com.
Put me on standing order
Notify me when new releases are available (no standing order will be created)