Tuesday, November 12, 2013

Doe v. Group Hospitalization & Medical Services case brief

Doe v. Group Hospitalization & Medical Services case brief summary
3 F.3d 80 (1993)


CASE SYNOPSIS
Appellants, a law firm and a partner, challenged a decision on cross-motions for summary judgment before the United States District Court for the Eastern District of Virginia affirming appellee insurer's denial of benefits under the Employee Retirement Insurance Security Act,29 U.S.C.S. § 1132(a)(1)(B).

CASE FACTS

Relying on contractual language excluding benefits for bone marrow transplants for treatment of multiple myeloma, as well as benefits for "related" services and supplies, appellee insurer denied benefits necessary to treat a rare form of blood cancer. Appellants, law firm and partner, challenged the denial of benefits under the Employee Retirement Insurance Security Act, 29 U.S.C.S. § 1132(a)(1)(B). On cross-motions for summary judgment, the district court entered judgment for the insurer, holding that it properly denied coverage based on the contract and amendments.

DISCUSSION


  • On appeal, the court applied a less deferential standard of review by reason of appellees' financial interest in the outcome of its decision. 
  • Despite finding that the insurer properly amended its policy and properly took that amendment into account in deciding to deny benefits, the court held that the insurer abused its discretionary fiduciary powers in construing the amended language to exclude chemotherapy and radiation therapy by interpreting those treatments as "services or supplies for or related to" a bone marrow transplant.

CONCLUSION
The court reversed the district court's grant of summary judgment to the insurer.


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