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John B. v. Connecticut General Life Insurance Co.

United States District Court, D. Utah

April 3, 2017

JOHN B., LINDA B., and MATTHEW B., Plaintiffs,
v.
CONNECTICUT GENERAL LIFE INSURANCE COMPANY, CIGNA BEHAVIORAL HEALTH and INTEL CORPORATION MEDICAL BENEFIT PLAN, Defendants.

          MEMORANDUM DECISION AND ORDER

          Bruce S. Jenkins United States Senior District Judge

         This matter came before the court for hearing on March 23, 2017. Brian S. King appeared on behalf of Plaintiffs John B., Linda B., and Matthew B. (collectively "B. Family"). James L. Barnett and Jack M. Englert appeared on behalf of Defendants Connecticut General Life Insurance Company and Cigna Behavioral Health, Inc. (collectively "Cigna") and Defendant Intel Corporation Medical Benefit Plan ("Plan").

         Having considered the parties' briefs, the evidence presented, the arguments of counsel, and the relevant law, the court finds that Cigna's decision to deny coverage of Matthew B.'s residential treatment at Island View Residential Treatment Center ("Island View") after March 6, 2013 was not arbitrary and capricious.

         As such, Defendants' combined summary judgment motion is GRANTED.

         BACKGROUND

         The Plan is a self-funded employee benefit plan sponsored by Intel Corporation. Cigna is the Plan's claims administrator. During the time period relevant to this case, Matthew B. was a covered dependent under the Plan.

         In order for medical services to be covered under the Plan, such services must meet Cigna's guidelines for medical necessity. In the Cigna Standards and Guidelines/Medical Necessity Criteria for Treatment of Behavioral Health and Substance Use Disorders ("Cigna Standards and Guidelines'"), the following "basic elements of medical necessity" are identified for residential mental health treatment for children and adolescents:

         [H]ealth care services that a Provider, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

a) Required to meet the essential health needs of the patient;
b) Consistent with the diagnosis of the condition for which they are required;
c) Consistent in type, frequency and duration of treatment with scientifically-based guidelines as determined by medical research;
d) Required for purposes other than the convenience of the provider or the comfort of the patient;
e) Rendered in the least intensive setting that is appropriate for the delivery of health care.

         Rec. 332.

         In addition, the Cigna Standards and Guidelines identify criteria that children and adolescents, once admitted to a residential treatment facility, must meet for continued stay:

         1. The individual continues to meet all basic elements ...


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