| Year |
Case |
Court |
Claim |
Disputed Subject |
Disposition |
Insurer's Decision |
| 1996 |
Bancroft and Bancroft v. Tecumseh Products |
US District Court for the Eastern District of Michigan, Southern
Division |
Sought reimbursement for breast reduction surgery; denied
on medical necessity grounds. |
Court found that Plan administrator improperly denied benefits
in an arbitrary and capricious manner. |
Judgment entered for the plaintiff. |
Reversed. |
| 1999 |
Bauer v. Country Life Insurance |
US District Court for Northern District of Illinois |
Sought preliminary and permanent injunction for high dose
chemotherapy with allogenic bone marrow transplant after medical necessity
denial. |
Procedure found to be experimental and thus excluded from
the policy. There was no evidence that the Plan administrator acted in an
arbitrary or capricious manner. |
Judgment entered for the Plan. |
Affirmed. |
| 1996 |
Bedrick v. Travelers Insurance |
US Court of Appeals, 4th Circuit |
Appeal of summary judgment in favor of Plan regarding the
denial of physical, occupational, and speech therapy benefits. |
On appeal, the court found the patient did not receive a
"full and fair" review. |
Reversed judgment in regards to physical and occupational
therapy and remanded with instructions to grant summary judgment for the
plaintiff. Affirmed all other aspects of judgment, including denial of speech
benefits specifically excluded under the contract. |
Reversed in part, affirmed in part. |
| 1994 |
Blue Cross Blue Shield of Virginia v. Keller |
Supreme Court of Virginia |
Appeal of summary judgment awarded to Plan regarding denial
of benefits on medical necessity grounds. |
Court of Appeals found that there was no evidence presented
to show that the Plan abused its discretion. |
Affirmed lower court's summary judgment. |
Affirmed. |
| 2001 |
Burrell v. United Health Care Insurance |
US District Court for the Eastern District of Pennsylvania
|
Made bad faith claim regarding denial of coverage of inpatient
stay for post-traumatic stress disorder. Plan argued that refusal was based
on both medical necessity grounds as well as ineligible treatment facility.
|
Court found that there was no clear evidence that the Plan
acted in an arbitrary or capricious manner. |
Partial summary judgment entered for Plan. |
Affirmed. |
| 1996 |
Bushman v. State Mutual Life |
US District Court for the Northern District of Illinois,
Eastern Division |
Sought injunction in regards to medical necessity denial
of high-dose chemotherapy and bone marrow transplant. |
Court found that the policy language clearly stated that
the plaintiff's illness was excluded from coverage and that the plaintiff
failed to show that the Plan acted in an arbitrary and capricious manner.
|
Summary judgment entered for the Plan. |
Affirmed. |
| 1993 |
Camelot Care v. Planters Lifesavers |
US District Court for the Northern District of Illinois,
Eastern Division |
Sought reimbursement for care delivered. Plan defined provider
as "primarily" a "custodial care" facility and not a "hospital," and thereby
expressly excluded it from reimbursement under the Plan's contract. |
Court found that the summary Plan description defined neither
custodial nor domiciliary care that was excluded from coverage. It found
the provider to be a hospital for the Plan's purposes. |
Judgment entered in favor of plaintiff. |
Reversed. |
| 2000 |
Chemacki v. Meijer, Inc. |
US District Court, Western District of Michigan, Southern
Division |
Sought reimbursement for immunotherapy and allergy antigen
injections after medical necessity denial. |
Claim fell outside 1-year window following denial notification.
Plan administrator also was found not to have acted in an arbitrary and
capricious manner. |
Judgment entered for the Plan. |
Affirmed. |
| 1996 |
Couri v. Guardian Life |
US District Court for the Northern District of Illinois,
Eastern Division |
Sought dental benefits denied on medical necessity grounds.
Plan sought summary judgment. |
Court found that genuine issues of material fact existed
regarding whether the insurer's actions constituted arbitrary and capricious
conduct. |
Summary judgment was denied. |
Reversed. |
| 1998 |
Crocco v. Xerox and American Psych Management, Inc. |
US Court of Appeals, 2nd Circuit |
Appeal of judgment in favor of plaintiff regarding the Plan's
"full and fair" review guaranteed under ERISA when making benefit determinations.
|
On appeal, the court upheld the previous ruling that the
Plan's administrator acted in an arbitrary and capricious manner and remanded
the case for a full and fair review. It also found that Xerox was not the
administrator in this case, dismissing Xerox from the suit. |
Affirmed in part, reversed in part. |
Reversed. |
| 1998 |
D'Angelo v. Blue Cross Blue Shield of Central New York |
Supreme Court of New York, Appellate Division, 3rd Department
|
Appeal of judgment in favor of plaintiff regarding benefits
denied on medical necessity grounds. Plan argued that verdict was not supported
by legally sufficient evidence. |
On appeal, the court found that the evidence was legally
sufficient. |
Affirmed. |
Reversed. |
| 2000 |
Delmarva Health Plan v. Aceto |
Court of Chancery of Delaware, New Castle |
Plan sought declaration that it had no duty to provide coverage
for a lung transplant. |
Court found that the policy did not expressly exclude the
procedure and that a policyholder could reasonably expect that services
necessary to life would be provided. |
Summary judgment entered for Aceto. |
Reversed. |
| 1993 |
Dettmer Clinic v. Associated Insurance |
US District Court for the Northern District of Indiana, South
Bend Division |
Chiropractor sought reimbursement for rendered services denied
on medical necessity grounds. |
Court upheld the insurer's right to determine medical necessity.
|
Summary judgment awarded to Plan. |
Affirmed. |
| 1992 |
Deville Nursing Service v. Metropolitan Life |
US District Court for the Western District of Louisiana,
Lake Charles Division |
Sought reimbursement for custodial care services denied on
medical necessity grounds. |
Court found that Plan's contractual language clearly states
that custodial care is not a covered service. Plan's decision was not arbitrary
or capricious. |
Summary judgment entered for Plan. |
Affirmed. |
| 1997 |
Dowden v. Blue Cross Blue Shield of Texas |
US Court of Appeals, 5th Circuit |
Appeal of summary judgment in favor of Plan regarding the
denial of expenses incurred in treatment of silicone breast implant complications.
|
On appeal, the court affirmed the lower court's ruling, finding
nothing arbitrary or capricious in the decision-making process. |
Affirmed. |
Affirmed. |
| 1996 |
Esdale v. American Community Mutual Insurance |
US District Court for the Northern District of Illinois,
Eastern Division |
Sought benefits for high-dose chemotherapy with peripheral
stem cell rescue denied on medical necessity grounds as experimental. Plan
sought summary judgment. |
Court found that evidence presented revealed that the experimental
status of the treatment was unclear in the literature. |
Summary judgment was denied. |
Reversed. |
| 1993 |
Evans v. Blue Cross Blue Shield of South Carolina |
US District Court for the District of South Carolina |
Sought reimbursement for radial keratotomy denied on medical
necessity grounds. |
Court found that the procedure did not meet the requirements
of medical necessity set forth by the contract. |
Judgment and attorney's fees awarded to Plan. |
Affirmed. |
| 1992 |
Farley v. Benefit Trust Life Insurance |
US Court of Appeals, 8th Circuit |
Appeal of judgment in favor of Plan regarding the denial
of high-dose chemotherapy and allogenic bone marrow transplant on medical
necessity grounds. |
On appeal, the court found that the burden of proof was on
the plaintiff to show that the procedure was not experimental. |
Affirmed. |
Affirmed. |
| 1994 |
Fenio v. Mutual of Omaha |
US District Court for the Southern District of Florida |
Sought preliminary injunction for high-dose chemotherapy
and allogenic bone marrow transplant denied on medical necessity grounds.
|
Court found on review of evidence that patient demonstrated
a substantial likelihood of success on the merits. |
Preliminary injunction ordered for plaintiff. |
Reversed. |
| 1993 |
Florence Nightingale Nursing Service v. Blue Cross Blue Shield
of Alabama |
US District Court for the Northern District of Alabama, Southern
Division |
Sought reimbursement for services provided. Plan argued that
services charges were unreasonable and that nursing care after IV removal
was not medically necessary. |
Court found that the Plan administrator had a conflict of
interest that tainted his judgment. Nursing charges were found to be reasonable.
|
Payment awarded to plaintiff. |
Reversed. |
| 1993 |
Fuja v. Benefit Trust Life |
US Court of Appeals, 7th Circuit |
Appeal of judgment in favor of plaintiff regarding the denial
of "experimental" cancer therapy on medical necessity grounds. |
On appeal, the court reversed the lower court's interpretation
of experimental, finding that the treatment in this case was clearly experimental.
|
Reversed. |
Affirmed. |
| 1995 |
Grethe v. Trustmark Insurance |
US District Court for the Northern District of Illinois,
Eastern Division |
Sought preliminary injunction and benefits for high-dose
chemotherapy and allogenic bone marrow transplant denied on medical necessity
grounds. |
The court, after de novo review, found that the plaintiff
had not met her burden of establishing that the proposed treatment met all
the criteria for medical necessity as defined by the policy. |
Preliminary injunction was denied. |
Affirmed. |
| 1996 |
Harrison v. Aetna Life |
US District Court for the Middle District of Florida, Orlando
Division |
Sought reimbursement for jaw surgery denied on medical necessity
grounds. |
Court found that the insurer actually extended coverage not
only through its coverage provisions but also through some of its limitations.
The surgery was found to be medically necessary and not done for cosmetic
purposes. |
Damages rewarded to plaintiff. |
Reversed. |
| 1993 |
Heasley and Heasley v. Belden and Blake Corporation |
US Court of Appeals, 3rd Circuit |
Appeal of judgment in favor of plaintiff regarding the denial
of liver/pancreas transplant benefits on medical necessity grounds. |
On appeal, the court found that the lower court's analysis
was suspect, as it was unable to be determined whether the procedure was
experimental. |
Judgment vacated and remanded. |
Affirmed. |
| 1993 |
Heil v. Nationwide Life |
US Court of Appeals, 6th Circuit |
Appeal of summary judgment awarded to Plan regarding the
medical necessity denial of plaintiff's inpatient psychiatric treatment.
|
Court of Appeals found the lower court erred by not reviewing
the entire Plan and making its own determination regarding the appropriate
standard of review rather than relying on the stipulation made by the parties.
Secondly, it erred when it determined that, as a matter of law, the treatment
was not medically necessary. |
Vacated the judgment and remanded for further proceedings.
|
Reversed. |
| 2001 |
Hundley v. Wenzel and Conseco Medical Insurance |
Missouri Court of Appeals, Western District |
Appeal of judgment in favor of Plan regarding denial of chiropractic
care on medical necessity grounds. |
On appeal, the court reversed the trial court's findings.
It found that the medical director made his decision in an arbitrary and
capricious manner. |
Reversed and remanded. |
Reversed. |
| 1999 |
Jones v. Kodak Medical Assistance Plan |
US Court of Appeals, 10th Circuit |
Appeal of judgment in favor of Plan regarding denial of inpatient
substance abuse treatment and allegation that insurer acted arbitrarily
and capriciously in its denial determination. |
The case contained no medical necessity definition per se
but instead included a provision construed by the court as limiting treatment
to the guidelines used by the managed behavioral health subcontractor. |
Judgment entered for the defendant. |
Affirmed. |
| 1999 |
Hunter v. Wal-Mart Stores |
US District Court for the Eastern District of Arkansas, Western
Division |
Sought reimbursement for hysterectomy twice denied by Plan
on medical necessity grounds. |
Plan administrator found to have abused his discretion because
the involved physicians determined that the operation was not the next therapeutic
step, rather than determining that the operation was not medically necessary.
|
Judgment entered for plaintiff. |
Reversed. |
| 2000 |
Juliano v. HMO of New Jersey |
US Court of Appeals, 2nd Circuit |
Appeal of judgment for reimbursement for home nursing care
denied on medical necessity grounds. Plan argued that its discretion allows
for it to offer care at skilled nursing facilities and that private care
was not medically necessary. |
Initial court found that the rates of home nursing were actually
less than that of the skilled nursing facility. On appeal, the court found
that additional proceedings were needed to assess damages. |
Vacated and remanded. |
Reversed. |
| 1998 |
Killian and Killian v. HealthSource |
US Court of Appeals, 6th Circuit |
Appeal of judgment citing arbitrary and capricious behavior
by Plan in regards to denial of breast cancer treatment on medical necessity
grounds. |
On appeal, court found the Plan to be arbitrary and capricious
in considering additional evidence after deadlines, but not so in making
its determination. |
Case was affirmed in part, reversed in part, and remanded
for further proceedings. |
Affirmed. |
| 1993 |
Koenig v. Metropolitan Life |
US District Court for the Northern District of Illinois,
Eastern Division |
Sought reimbursement for substance abuse care denied by Plan.
Plan argued that plaintiff did not exhaust internal remedies. |
The court found that the evidence showed that continued internal
appeal attempts would have proven futile and useless. |
Plan's motion to dismiss the case was denied. |
Reversed. |
| 1992 |
Lehman v. Mutual of Omaha |
US District Court for the District of Arizona |
Sought reimbursement for high-dose chemotherapy and allogenic
bone marrow transplant denied on medical necessity grounds. |
Court found after de novo review that the evidence presented
suggested that the procedure was experimental and, therefore, not covered
under the Plan's contract. |
Judgment entered for the Plan. |
Affirmed. |
| 1999 |
Lewis v. Trustmark Insurance |
US Court of Appeals, 4th Circuit |
Appeal of summary judgment in favor of Plan regarding denial
of benefits for high-dose chemotherapy and allogenic bone marrow transplant
on medical necessity grounds. |
On appeal, the court was unable to conclude that the Plan
was unreasonable in their interpretation of the policy. |
Affirmed. |
Affirmed. |
| 1992 |
Mann v. Prudential Insurance |
US District Court for the Southern District of Florida |
Sought benefits for uterine monitoring services denied on
medical necessity grounds as specifically excluded. |
Court found that the plaintiff failed to provide evidence
that the Plan's decision was arbitrary or capricious. |
Summary judgment entered for Plan. |
Affirmed. |
| 1996 |
Maune v. International Brotherhood of Electrical Workers
|
US Court of Appeals, 8th Circuit |
Appeal of summary judgment in favor of Plan regarding the
denial of benefits for breast implant removal. |
On appeal, the court upheld the finding that the procedure
was not medically necessary. The court found the case not trivial, reversing
the legal fee rulings. |
Affirmed in part, reversed in part. |
Affirmed. |
| 1992 |
McGee v. Equicor-Equitable HCA |
US Court of Appeals, 10th Circuit |
Appeal of judgment in favor of Plan regarding denial of rehabilitative
care on medical necessity grounds. |
On appeal, the court affirmed that the patient's transfer
severed relations with Plan physicians and prevented the Plan from making
necessary predeterminations of improvement as required by contract. |
Affirmed. |
Affirmed. |
| 1998 |
McGraw v. Prudential Insurance |
US Court of Appeals, 10th Circuit |
Appeal of summary judgment in favor of Plan regarding the
denial of physical therapy benefits on medical necessity grounds. |
On appeal, the court affirmed that ERISA governed action
and reversed conclusion that denial of benefits was not arbitrary and capricious.
|
Case was affirmed in part, reversed in part, and remanded
for further proceedings. |
Reversed. |
| 1999 |
Meditrust v. Sterling Chemicals |
US Court of Appeals, 5th Circuit |
Appeal of summary judgment in favor of Plan regarding denial
of rehabilitative care on medical necessity grounds. |
Court of Appeals found that the lower court had applied the
correct discretionary standard and that the Plan did not act in an arbitrary
and capricious manner. |
Affirmed summary judgment in favor of Plan. |
Affirmed. |
| 1995 |
Miller v. United Welfare Fund |
US Court of Appeals, 2nd Circuit |
Appeal of judgment in favor of plaintiff regarding the denial
private nursing benefits on medical necessity grounds. |
On appeal, the court upheld that the Plan acted arbitrarily
and capriciously. It also found that the lower court erred by considering
evidence outside of the administrative record. |
Case was remanded to trial court with instructions. |
Reversed. |
| 2001 |
Milone v. Exclusive Healthcare |
US Court of Appeals, 8th Circuit |
Sought pre-certification for breast reduction surgery after
medical necessity denial. Plan later appealed, arguing that its contract
had a direct exclusion for the surgery in her case. |
Plan's denial was found to be internally inconsistent and
ambiguous. Other women had been previously approved. On appeal, the court
disagreed with the Plan's interpretation of the contractual language. |
Judgment entered for the plaintiff. Lower court decision
upheld on appeal. |
Reversed. |
| 1999 |
Neurocare and Whitmore v. Principal Life |
US District Court for Northern District of California |
Sought reimbursement for rehabilitation services delivered
after medical necessity denial. |
Plan found to rely on excerpts of only one of the treating
physicians in exclusion of the others, thus abusing its discretion. |
Judgment entered for the plaintiffs. |
Reversed. |
| 1997 |
Nichols v. Trustmark Insurance |
US District Court for the Northern District of Ohio, Eastern
Division |
Sought benefits for high-dose chemotherapy and allogenic
bone marrow transplant denied by Plan on medical necessity grounds. Plan
sought summary judgment. |
Court found that genuine issues of material fact exist as
to whether the treatment is experimental and to whether the Plan had reasonable
justification' for its decision to deny benefits. |
Plan's motion for summary judgment was denied. |
Reversed. |
| 1995 |
Personnel Pool of Ocean County v. Trustees Fund |
US District Court for the District of New Jersey |
Sought reimbursement for nursing benefits denied on medical
necessity grounds. |
Court found that the decision was reasonable and not arbitrary
and capricious. |
Judgment with prejudice entered for Plan. |
Affirmed. |
| 2000 |
Risenhoover v. Bayer |
US District Court, Southern District of New York |
Sought preliminary injunction to prevent Plan from discontinuing
IV treatments for Lyme disease after medical necessity denial. |
Denial found not to be arbitrary or capricious. |
Judgment entered for the Plan. |
Affirmed. |
| 1993 |
Scalamandre v. Oxford Health Plans |
US District Court for the Eastern District of New York |
Sought reimbursement for high-dose chemotherapy and allogenic
bone marrow transplant received outside of Plan's chosen hospitals and denied
on medical necessity grounds. |
Court found that the contract language and actions of the
Plan made it impossible to comply with pre-certification requirements. |
Full benefits awarded to plaintiff. |
Reversed. |
| 1997 |
Semmler v. Metropolitan Life |
US District Court for the Southern District of New York |
Sought benefits for patient-controlled anesthesia denied
by Plan. Plan claimed that the service was covered in the physician's package
fee and reimbursement would be equivalent to double billing. |
Court found no abuse of discretion using an arbitrary and
capricious standard. |
On appeal, the plaintiff's motion to vacate the judgment
was denied. |
Affirmed. |
| 1994 |
Sheppard and Enoch Pratt Hospital v. Travelers Insurance
|
US Court of Appeals, 4th Circuit |
Appeal of judgment awarded to Plan regarding denial of partial
benefits of 16-month long hospital stay on medical necessity grounds. |
Court of Appeals affirmed that the Plan administrator's denial
of coverage was not an abuse of discretion. The Plan's failure to provide
specific reasons as to why the hospitalization was not medically necessary
for the full 16 months was not necessary. |
Affirmed lower court's judgment. |
Affirmed. |
| 2001 |
Smith v. Newport News |
US District Court, Eastern District of Virginia |
Sought injunction in regards to medical necessity denial
of coverage for high-dose chemotherapy. |
Questioned whether Plan administrator abused his discretion
in making the decision. |
Preliminary injunction granted. |
Reversed. |
| 1993 |
Snell v. Travelers Insurance |
US District Court for the Eastern District of Pennsylvania
|
Sought reimbursement for high-dose chemotherapy and allogenic
bone marrow transplant denied on medical necessity grounds. |
Court found that the Plan was only beholden to a deferential
standard and the Plan's decision was not arbitrary and capricious. |
Summary judgment awarded to the Plan. |
Affirmed. |
| 1997 |
Sophie and Sophie v. Lincoln National Life |
US District Court for Northern District of Illinois, Eastern
Division |
Sought benefits for artificial insemination denied on medical
necessity grounds. |
Court found that artificial insemination was not a covered
benefit and further held that the plaintiffs could not show that, in the
absence of treatment, state of health would deteriorate. |
Summary judgment entered for Plan. |
Affirmed. |
| 1996 |
Sven v. Principal Mutual Life |
US District Court for the Northern District of Illinois,
Eastern Division |
Sought reimbursement for allergy treatments denied on medical
necessity grounds. Plan sought summary judgment. |
Court found that de novo standard was most appropriate. |
Summary judgment was denied. |
Reversed. |
| 1994 |
Trustees of Northwest Laundry v. Burzynski |
US Court of Appeals, 5th Circuit |
Appeal of judgment in favor of Plan regarding the denial
of reimbursement for provider's services. |
On appeal, the court affirmed the lower court's ruling that
the provider defrauded the Plan by submitting claims for unorthodox cancer
treatments. |
Affirmed. |
Affirmed. |
| 2000 |
Trustmark Life v. University of Chicago Hospitals |
US Court of Appeals, 7th Circuit |
Appeal of judgment for Plan to recover money spent on breast
cancer treatment later found to be medically unnecessary. |
On appeal, the court found that the provider hospital was
entitled to keep the money under the theory of estoppel. |
Reversed. |
Reversed. |
| 1999 |
Wellness Aerobic Clinic v. United HealthCare |
US District Court for Eastern District of Louisiana |
Sought reimbursement for rehabilitation services delivered
after medical necessity denial. |
Denial of benefits found to be legally correct and not an
abuse of discretion. |
Summary judgment for Plan |
Affirmed. |
| 1994 |
Whitehead v. Federal Express |
US District Court for the Western District of Tennessee,
Western Division |
Sought preliminary injunction for high dose chemotherapy
with peripheral stem cell rescue denied on medical necessity grounds. |
Court found it did not have the authority to usurp the power
of Plan to interpret contract terms. It did not find that the Plan acted
in an arbitrary and capricious manner. |
Preliminary injunction denied. |
Affirmed. |
