Narrative Opinion Summary
This case involves a dispute between M.A., a beneficiary of a self-funded health plan, and Regence BlueCross BlueShield of Utah, the plan's administrator, regarding the denial of insurance coverage for biofeedback therapy intended to treat M.A.'s chronic constipation. M.A. filed a lawsuit against Regence, alleging breach of contract, breach of the implied covenant of good faith and fair dealing, and intentional infliction of emotional distress after Regence denied coverage on the grounds that the treatment did not meet the plan's criteria for medical necessity. The district court granted summary judgment in favor of Regence, concluding that the denial was fairly debatable based on evaluations by multiple physicians who found the documentation insufficient to establish medical necessity. M.A. appealed, arguing that the denial was not reasonable and that there was a material dispute of fact regarding the medical necessity of the treatment. The appellate court, reviewing the summary judgment for correctness, affirmed the district court's decision, holding that Regence did not breach its duty of good faith as the denial was based on a legitimate, debatable issue of medical necessity.
Legal Issues Addressed
Breach of the Implied Covenant of Good Faith and Fair Dealingsubscribe to see similar legal issues
Application: The court evaluated whether Regence breached the implied covenant by denying M.A.'s claim for biofeedback therapy based on the contention that the denial was fairly debatable.
Reasoning: M.A. subsequently sued Regence for breach of the implied covenant of good faith and fair dealing. The district court ruled in favor of Regence, granting summary judgment, which M.A. is now appealing.
Correctness Review of Summary Judgmentsubscribe to see similar legal issues
Application: The appellate court conducts a correctness review of the summary judgment, assessing whether the district court erred in its legal conclusions regarding the fairly debatable nature of the insurance claim.
Reasoning: The court conducts a correctness review of summary judgment without deference to the lower court's legal conclusions.
Criteria for Medical Necessity in Health Insurance Coveragesubscribe to see similar legal issues
Application: Regence's denial was based on the failure to meet specific criteria that established medical necessity for biofeedback therapy, as per their guidelines, which were not sufficiently contradicted by M.A.'s submissions.
Reasoning: Regence denied the pre-authorization, citing a physician's review that indicated the documentation did not sufficiently demonstrate a diagnosis of dyssynergia type constipation or functional constipation, nor did it establish a failed three-month trial of standard treatments.
Fairly Debatable Standard in Insurance Claimssubscribe to see similar legal issues
Application: The court determined that Regence's denial of coverage was fairly debatable, as reasonable minds could differ on the validity of the claim given the evaluations of four physicians.
Reasoning: The court also noted that the documentation provided by M.A. lacked the necessary support for her claims, and it concluded there was no contractual relationship between M.A. and Regence.