T. E. v. Anthem Blue Cross Blue Shield -Western District of Kentucky at Louisville
Split Score
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Case Summary
Disposition
Affirmed in Part
The Sixth Circuit held that Anthem acted arbitrarily and capriciously under ERISA when it stopped paying for a minor’s residential mental-health treatment after initially approving 21 days, because Anthem ignored treating-clinician evidence, cherry-picked records, and offered scant, shifting rationales. The court vacated the district court’s judgment on the ERISA claim and ordered a remand to Anthem for a full and fair review, but affirmed the dismissal of the Mental Health Parity Act claim for lack of evidentiary support.
Circuit Split Identified
Legal Issue
Whether a court reviewing an ERISA benefits denial under the arbitrary-and-capricious standard must confine its review to the reasons given in the plan administrator’s denial letters or may also consider internal notes and reviewer reports that were not disclosed to the claimant.
Circuit Positions
Judicial review is limited to the explanations contained in the administrator’s denial letters.
Question unresolved; court assumed review could include internal materials without deciding the legal issue.
Conflict Summary
The First and Tenth Circuits limit judicial review to the rationales articulated in the plan administrator’s denial letters, while the Sixth Circuit has expressly left the question open; in this opinion it considered internal materials but stated it “need not resolve” the scope-of-review question, thereby acknowledging – but not joining – the restrictive approach adopted by other circuits.