It often seems that insurance companies put their needs and bottom line ahead of the needs of their clients. Usually, this comes when insurers deny claims, with such explanations as the recommended surgery was unnecessary or that the claimant didn’t try to avoid the surgery by seeking rehab or treatment. These rulings come from people reviewing paperwork or circumstances, while a claimant has a doctor treating them that says the surgery is necessary.
Garner V. Central States
In this recent case, Dorothy Garner suffered from neck and back pain that was severe and increasing despite medication and treatment. Based on the results of an MRI, her doctor recommended surgery. Garner sought to cover the expense by filing a claim as a beneficiary of her husband’s ERISA plan sponsored by United Parcel Service.
The carrier, Central States, denied her claim as not “medically necessary.” The decision was made by a doctor who did an Independent Medical Review. However, it came to light that the provider did not provide the reviewer with a copy of the MRI that prompted the surgery nor the case notes provided by the claimant’s doctor. Without these missing pieces of evidence, the IMR doctor denied the claim, saying there was no basis for the surgery. Central States then used his comments as the basis of its denial letter.
An initial appeal
Garner appealed the denial after having a physician review her medical file. Central States conducted the appeal using a neurological surgeon. While the surgeon had all the casework, he too rejected the claim, writing that Garner did not do enough conservative measures since she only tried medication. Central States denied the appeal.
Lawsuit against ERISA
Garner turned to the District Court, which ruled in her favor. It cited three points:
- Central States didn’t initially provide the MRI and office visit records.
- The policy did not require claimants to explore every conservation option before surgery.
- Garner had tried exercises to relieve the pain.
4th Circuit upholds the appeal
It was now Central States’ turn to appeal the finding. The Fourth Circuit agreed that the carrier had abused its discretion, even though regulations generally favor the carrier’s ability to deny a claim. The Circuit Court supported the District Court’s findings, pointing out the Central States owed clients a reasoned determination, which it failed to do through three determinations.
There’s hope for those denied
Garner’s tenacious approach finally got her the much-needed ERISA benefits she needed and deserved. Going through this many-tiered process requires the skill of attorneys with experience handling ERISA health insurance claims, particularly when the carrier initially denies the claim.