By: Amanda Sonneborn and John Duke

The U.S. District Court for the Central District of California recently held in Dubaich v. Connecticut General Life Insurance Co., C.D. Cal., No. 2L11-cv-10670-DMG-AJW (April 25, 2013), that a health plan participant could not obtain coverage for treatment of her degenerative disc disease, because the plan “ineluctably and unambiguously” excluded coverage for the procedure recommended by her physician.

Danica Dubaich was a participant in a self-funded employee medical benefit plan governed by ERISA and administered by Connecticut General Life Insurance Co.  Plaintiff suffered from a multi-level degenerative back disease and her physician recommended that she have the discs replaced with artificial discs.  However, the medical plan’s administrator (“Cigna) denied coverage for the procedure because the artificial disc replacement recommended by her physician was not one of the two disc replacements approved by the U.S. Food and Drug Administration, and the treatment was therefore “experimental” and “not medically necessary” as required for coverage under the terms of the plan. 

Plaintiff  appealed the denial under the internal appeal procedures set forth in the plan.  In support of her appeal, her physician submitted several peer-reviewed studies to try to show that the procedure he recommended was both safe and effective.  Her first appeal was denied because “the current peer-reviewed scientific medical literature is inadequate to establish the clinical utility, safety and efficacy” of the procedure and was “therefore excluded from coverage under your medical benefit plan as experimental/investigational/unproven.”  Her second appeal was denied by a “Benefits Appeal Committee” for similar reasons.

Plaintiff filed suit under ERISA.  She made three arguments.  First, she argued that the court should not defer to the Appeal’s Committee decision because, while the plan granted broad discretion to interpret its terms to the plan administrator, there was no evidence that the plan administrator had ever delegated its authority to the Appeals Committee.  Second, she claimed that the insurer bore the burden of proving that the procedure recommended by her physician was “experimental”.  Third, Plaintiff contended that the insurer could not meet this burden.

Following a bench trial, the court agreed with Plaintiff first two contentions but nevertheless affirmed Cigna’s denial of coverage, agreeing that the plan unambiguously excluded the type of “multi-level” artificial disc replacement prescribed by her physician.  According to the court, the plan’s terms clearly listed her proposed disc replacement as a treatment that Cigna “does not cover” because it was considered “experimental, investigational or unproven.”  Although Plaintiff submitted medical literature in support of her position that such treatment should not be considered experimental, the court said that it could not order Cigna “to rewrite its policy.”  In short, it did not matter that the plan gave a reason for why the procedure sought by Plaintiff was excluded from coverage because the procedure was already expressly not covered.  Affirming the denial of coverage, the court concluded that Cigna “was not only correct to deny the claim in accordance with the Plan language, but required by law to do so as a fiduciary of the Plan.”