ERISA-First Circuit Rules That The Administrative Record Needed To Be Supplemented Before It Could Be Concluded That The Medical Treatment At Issue Was Not Medically Necessary

In Doe v. Harvard Pilgrim Health Care, Inc., No. 17-2078 (1st Cir. 2018), Jane Doe’s insurer, Harvard Pilgrim Health Care (“HPHC”), deemed part of the time Doe spent at a mental health residential treatment facility not medically necessary under the health care benefits plan established by the employer of Doe’s parent. HPHC therefore denied coverage for that portion of the treatment.  After several unsuccessful administrative appeals, Doe sued HPHC in federal court under ERISA.

On de novo review, the district court agreed with HPHC’s determination that continued residential treatment was not medically necessary for Doe.  However, upon review by the First Circuit Court of Appeals (the “Court”), the Court concluded that the administrative record upon which the district court based its finding should have been supplemented.  As a result, the Court reversed in part, vacated in part, and remanded for further proceedings.

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