Plan participants and beneficiaries are entitled to a full and fair review of their claims and adverse benefit determinations. As part of this process, plans must address a treating provider’s recommendation for such treatment/coverage when making a determination that such treatment/coverage is not medically necessary.
In D.B. v. United Healthcare Ins. Co., (D. Utah 2023), a participant filed suit against two separate health plans related to denied claims for residential treatment for depression, anxiety, lack of focus and extreme hyperactivity. The district court dismissed one of the health plans because the terms of the plan only covered residential treatment centers if 24-hour onsite nursing services were provided. However, the district court held that the other health plan failed to “engage with and address” the child’s treating provider’s recommendation when it issued its denial letters and as a result, it’s determination that the child was medically and mentally stable was an abused of discretion. Accordingly, the district court ordered that the claim be reviewed and directed the plan administrator to specifically address the participant’s arguments in support of the child’s residential treatment coverage.