A federal district court recently overruled a self-funded, group health plan’s denial of benefits for a procedure that the plan determined to be “experimental,” and thus not covered by the plan. The court reviewed the plan’s benefit determination de novo, rather than applying the deferential standard of review that is available under ERISA, because the plan administrator, which had discretionary authority under the plan to interpret its terms, did not expressly delegate its discretionary authority to the employer’s Benefits Appeal Committee that conducted the final claim review. Accordingly, the court gave no deference to the plan’s final benefit determination, reviewed additional evidence related to the procedure in question that had not been considered by the committee, and concluded that the procedure was covered under the plan.
Dubaich v. Conn. Gen. Life. Ins. Co., 2:11-cv-10570-DMG-AJW (C.D. Cal. July 31, 2013).