LOS ANGELES, Aug. 22, 2014 /PRNewswire/ -- Kantor & Kantor today announced the U.S. Court of Appeals 9th Circuit decision in Pacific Shores Hospital v. United Behavioral Health, et al., a case in which a severely anorexic 43-year old woman sought benefits under her Wells Fargo employee health benefit plan for inpatient psychiatric treatment.
The claims administrator, United Behavioral Health ("UBH"), denied the claim as not medically necessary based on opinions its physician reviewers. Kantor & Kantor filed suit against UBH and the Wells Fargo & Company Health Plan. At trial, the district court ruled in favor of defendants.
On August 20, 2014, the U.S. Court of Appeals for the 9th Circuit reversed the district court's judgment. In a decision by Circuit Court Judge William A. Fletcher, the court held that UBH abused its discretion in denying benefits for the patient's treatment. The court determined "[t]here was a striking lack of care by" the UBH physicians which resulted in a plethora of errors. The court found that the UBH physicians mischaracterized the patient's medical history and condition, including her weight, suicide risk, caloric intake, and laxative abuse.
The court expressed concern that the administrative record in this complex case was "based entirely on telephone conversations and voicemail messages" which raised questions about the thoroughness and accuracy of the benefits determination.
"The decision is vindication for patients with eating disorders and other severe mental illness whose claims for benefits have been unfairly handled by UBH and other administrators," said Lisa Kantor, founding partner of Kantor & Kantor. "The decision cautions administrators to avoid the obvious mistakes, mischaracterizations, and contradictions that were prevalent in this case," said Kantor.
The court concluded: "The unhappy fact is that UBH acted as a fiduciary in name only, abusing the discretion with which it had been entrusted."
About Kantor & Kantor, LLP
Kantor & Kantor is the largest law firm in the country exclusively representing plaintiffs who have been denied insurance benefits from life, health, disability, and long-term care policies. The firm has extensive experience with the complex appeals process and federal court litigation of ERISA matters, and files more ERISA cases than any other law firm in California. For more information, log on to www.kantorlaw.net, call (800) 446-7529, or follow the firm at http://www.kantorlaw.net/Eating_Disorder_Blog.aspx.
SOURCE Kantor & Kantor, LLP