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Kantor & Kantor, LLP achieved another victory in a mental health benefits case from the District of Utah, Rachel S. v. Life and Health Benefits Plan of American Red Cross, No. 2:14-CV-778, 2020 WL 6204402 (D. Utah Oct. 22, 2020). In Rachel S., the plaintiff seeks benefits for residential treatment denied by Cigna, the Plan’s claims administrator. Rachel struggled with an eating disorder and in July 2012 she attempted suicide a second time. She was admitted to residential treatment and Cigna initially approved benefits.

On September 17, 2012, Rachel’s suicidal thoughts increased as she was required to eat. She engaged in attempts to reduce her food intake and was at 85% of her ideal body weight. The case notes specifically addressed whether Rachel was ready to step down to partial hospitalization and concluded that she needed too much supervision for step-down to be successful.

Nevertheless, on that same date, Cigna denied further residential treatment benefits claiming Rachel “would not kill herself because of her religious beliefs” (the court noted that assertion does not appear in the treatment records) and was “fully compliant with her meal plan.”

The court found that the reasons Cigna relied on for denying coverage are contrary to the record evidence. The court determined the record of Rachel’s residential treatment highlights the complexity of her condition. The court took particular note of an incident on November 27, 2012 when Rachel attempted suicide as she “wrapped a seatbelt around her neck and attempted to strangle herself.” Cigna, however, contends Rachel did not attempt suicide, but merely thought about it and even if it did occur, “it was of short duration and did not result in any injury to her.”

The court concluded that the facts do not support the claim that the incident was minor. The court found the relevant question, based on the industry standard, was not whether Rachel could step down for a few days and be okay but whether there were sufficient indicators to support her and sustain an ability not to engage in eating disorder behaviors when in a less restrictive setting.

On appeal, Cigna approved coverage through October 4, 2012 and then denied benefits. The court found Cigna’s denials stated it had denied benefits based on the terms of the Plan but both times Cigna failed to state how Rachel failed to meet Plan requirements for medical necessity. A subsequent external appeal was likewise denied without showing that the reviewer considered any portion of the Plan.

The court found Cigna is entitled to a deferential review based on the Plan’s grant of discretionary authority to Cigna. However, the court concluded a de novo standard of review should apply because the denial was not based on a valid exercise of discretion as Cigna did not apply the Plan language. The court found that none of Cigna’s denials referred to how Rachel failed to meet the Plan requirements for medical necessity based on accepted standards in the industry. The Cigna denials only referred to Cigna’s Guidelines, “which notably, are not part of the Plan.” The court found that Cigna’s Guidelines add other criteria that fail to show how they are keeping with industry standards.

The court found that Cigna did not answer the relevant question regarding medical necessity based on “accepted standards of medical practice.” The court found while Cigna reported that Rachel was improving in some areas, these areas do not reasonably show why Rachel no longer needed 24-hour care. For example, the fact that Rachel was “continuing to gain insight and weight” does not mean that Rachel had sufficient insight to sustain improvement when her body distortions and thoughts of restricting remained persistent. The court found thoughts of suicide “cannot be brushed aside by stating that she had no specific plan.” 

The court denied summary judgment for Cigna and concluded the evidence fails to show that Rachel could have safely stepped down from residential treatment. However, the court also concluded that “independent, expert evidence is needed to determine on what day” Rachel could have stepped down safely.

Finally, the court denied Cigna’s Motion to Strike notes of a telephone conversation because although the notes were not introduced during the administrative record, they may be relevant to an expert opining as to the date Rachel could have stepped down.

Rachel S. is represented by Kantor & Kantor, LLP Partner, Lisa Kantor. This notable decision summary was prepared by Kantor & Kantor, LLP Partner, Elizabeth Green. Lisa and Elizabeth are passionate about helping patients obtain health benefits for a range of health conditions and particularly for mental health disorders such as eating disorders.

If you are denied benefits for treatment, a procedure, or even medication, please contact us for a free consultation or use our online contact form. We are here to help you hold your insurance company accountable.