Doe v. Harvard Pilgrim Health Care, Inc.

The First Circuit reversed in part, vacated in part, and remanded for further proceedings the district court’s denial of Plaintiff’s challenge of Harvard Pilgrim Health Care’s (HPHC) denial of coverage for the cost of Plaintiff’s uncovered care at a mental health residential treatment facility, holding that the administrative record upon which the district court based its findings should have been supplemented. HPHC, Plaintiff’s insurer, deemed a portion of the time Plaintiff spent at the residential facility not medically necessary under the health care benefits plan established by the employer of Plaintiff’s parent and therefore denied coverage for that portion of the treatment. Plaintiff brought suit under ERISA, 29 U.S.C. 1001-1461. The district court affirmed on de novo review, concluding that continued residential treatment was not medically necessary for Plaintiff. The First Circuit vacated the district court’s order granting summary judgment for HPHC and remanded for further proceedings, holding (1) when a district court examines the denial of ERISA benefits de novo, the court’s factual findings are reviewed only for clear error; and (2) such a deferential review cannot properly be conducted in this case on the administrative record. View "Doe v. Harvard Pilgrim Health Care, Inc." on Justia Law