The claimant sought coverage for partial hospitalization and residential mental health treatment after outpatient care proved insufficient to manage serious psychiatric symptoms. Treating providers determined a higher level of care was medically necessary to stabilize the condition and prevent deterioration.
Humana curtailed coverage by applying restrictive medical-necessity standards to mental health treatment that were not applied to comparable medical or surgical care. Kantor & Kantor challenged both the denial itself and the standard of review governing ERISA benefit determinations in the Fifth Circuit.
Sitting en banc, the Fifth Circuit overruled prior precedent, clarified the default ERISA standard of review, and addressed parity principles governing mental health coverage. The decision reshaped ERISA litigation in the circuit and strengthened enforcement of federal mental health parity protections.
