The US District Court for Eastern Louisiana found breast reconstructions are only covered under the health plan if related to a mastectomy, not to alleviate back pain, as was the case in Thompson v Blue Cross Blue Shield of Louisiana.
James Thompson was covered under a Blue Cross Blue Shield of Louisiana health plan offered through his employer. In 1999 his daughter, Erica Thompson, consulted a doctor for her severe back pain. To alleviate the pain, the doctor recommended breast reduction surgery.
Erica underwent the operation, even after James consulted Blue Cross and was informed that such as a procedure was not covered.
After the operation, James sued Blue Cross for an alleged ERISA violation in their denial of payment. James argued that the plan’s “limitations and exclusions” section expressly excluded breast enlargements and reductions and created a conflict with its coverage of cosmetic surgery that allowed for breast reconstructions.
In a summary judgment, Judge Kurt Engelhardt found no conflict, as the plan provided for breast reconstructions in relation to a mastectomy. Erica’s reduction was unrelated to a mastectomy and therefore not covered under the plan.
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