ERISA-Eleventh Circuit Upholds Denial Of Claim For Out-Of-Network Health Care Benefits

In Lieberman v. United Healthcare Insurance Co., Nos. 10-12942, 10-13222 (11th Circuit 2011) (unpublished opinion), in a suit brought under ERISA, the plaintiff had alleged that the defendant, United Healthcare Insurance Company (“United”), inappropriately denied her claim for out-of-network health care benefits under her employer’s group health insurance plan (the “Plan”). The district court dismissed the plaintiff’s complaint, and the plaintiff appealed.

At issue was the method United used to determine the reimbursement due from the Plan, for the cost of a medical procedure received by the plaintiff’s daughter from a doctor who had not agreed to join United’s provider network, or to accept the discounted rates United pays network providers (that is, from an out-of-network provider). Although the Plan permits the plaintiff to obtain reimbursement for the cost of health care services she and her family receives from an out-of-network provider, the plaintiff’s Certificate of Coverage specifically grants United the discretion to choose from among four specified methods for determining the amount of the reimbursement.

The plaintiff stated that United improperly and arbitrarily picked a method that operated to minimize its financial responsibility. As a result, she was left financially responsible for $9,763.16 of a $10,000 service, so that, in effect, her benefit claim had been denied. However, the Court found that the Certificate expressly affords United the discretion to calculate reimbursement based on the method it selected -here, a method based on a percentage of the relevant Medicare rate. United had no obligation to select an alternative method that would have resulted in a higher reimbursement for the plaintiff. Therefore, the Court affirmed the district court’s decision to dismiss the plaintiff’s case.

Posted in:
Updated:

Comments are closed.