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Court defers to insurer on medical necessity

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in Compensation and Benefits,Human Resources

Providing health benefits is an expensive proposition and could get even more expensive if insurers and their agents don’t challenge treatment plans that call for excessive and unnecessary care. Litigating such claims also adds to cost.

But the good news is that courts considering an ERISA benefit claim may side with the insurer if the decision to deny a treatment was supported with evidence.

Recent case: Krysten has an eating disorder. She has insurance coverage through an ERISA employer plan.

She had to be hospitalized in a residential program, but the insurer periodically reviewed her care to see if residential care was necessary.

She sued when, after 60 days, the insurer concluded she had improved sufficiently to warrant transfer to a nonresidential program. The court agreed with the insurer and dismissed the case. (C. v. Blue Shield, No. 15-CV-02421, ND CA, 2016)

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