Killian v. Concert Health Plan

Dist. Ct. did not err in granting defendants-health plan and its administrator’s motion for summary judgment in ERISA action alleging that defendants wrongfully denied certain medical bills incurred during plaintiff’s treatment for cancer where plaintiff used physicians and hospital that were not in plan’s network of medical providers, and that defendants breached fiduciary duty by failing to alert plaintiff to fact that physician and hospital were not in defendant’s network before plaintiff had incurred said expenses. While plaintiff argued that plan’s denial was unreasonable where record was unclear as to actual plan that covered plaintiff’s medical expenses, Ct. found that defendant could deny instant claim where plaintiff was aware of precise plan to which she had enrolled, and where plaintiff conceded that doctors/hospital involved in cancer treatment were not within said network. Moreover, defendants did not breach any fiduciary duty, even though plaintiff made two telephone calls to plan on day of her admission into hospital to undergo cancer treatment since: (1) plaintiff did not timely alert defendant in either phone call that she had question as to whether said treatment would be covered under plan; and (2) plaintiff failed to follow instructions in plan to determine whether doctors or hospital were within applicable network. Remand, though, was required for re-determination of statutory damages arising out of defendants’ failure to timely provide copy of plan documents where Dist. Ct. failed to consider all of plaintiff’s arguments in support of such award. (Partial dissent filed.)