According to the opinion written by U.S. District Judge John T. Nixon, the Vanderbilt University-sponsored plan did not specifically spell out that a participant’s obese condition must persist for five “consecutive” years before surgery can be considered a covered option under the plan, but it was reasonable for the plan administrator to make that interpretation.
The plan’s claims payments are administered by Blue Cross Blue Shield of Tennessee (BCBST). The plan states that covered services are “[t]hose [services that are] medically necessary and appropriate.”
The case involves Jennifer Foster, who received health insurance coverage because her husband was a registered nurse at Vanderbilt Medical Center’s burn unit.
Two physicians deemed Foster as suffering from severe obesity, which resulted in windedness and related ailments such as aches in her hips and lower back. Foster was deemed as a good candidate for the laparoscopic LAP Band surgery.
Foster submitted the medical reports of the two doctors to Vanderbilt as grounds for having the surgery covered by the plan. However, her request was twice denied by BCBS because her doctors failed to submit information regarding her weight for the past five years, and therefore Foster may not have been morbidly obese until shortly before seeking coverage, according to the opinion.
Foster then appealed the two decisions to Vanderbilt. Foster submitted additional medical records and doctors notes stating that she had been 100 pounds over her ideal weight for the past five years, as well as a self-report of her weight over the past five years. She did not provide any medical records reflecting her weight for the years 2001 or 2003.
Foster filed the complaint in court, saying that Vanderbilt’s decision to throw out her claim was arbitrary and capricious and violated the Employee Retirement Income Security Act (ERISA – particularly that Vanderbilt manipulated the plan terms “diagnosis” and “persist” to require objective medical documentation of morbid obesity for five consecutive years. She also claimed that Vanderbilt violated ERISA by ignoring the recommendations of her doctors.
The court disagreed and said that Vanderbilt’s method for interpreting the plan was reasonable.
“ERISA does not require plan administrators to accord special deference to the opinions of treating physicians, particularly where there is credible, reliable evidence that conflicts with the treating physicians’ opinions,” Nixon wrote in the opinion.
The case is Foster v. Group Health Care Plan for Vanderbilt University ,M.D. Tenn., No. 06-0843, 7/5/07).