Baxter v. MBA Group Insurance Trust Health & Welfare Plan
2013 U.S. Dist. LEXIS 103063
| W.D. Wash. | 2013Background
- Baxter, diagnosed with intermediate-risk, early-stage prostate cancer in 2011, pursued proton therapy.
- Plan is the ERISA-governed Health and Welfare plan administered by Regence Blueshield.
- Regence denied proton therapy as not medically necessary under Policy 49.
- Plaintiff appealed; Regence affirmed on independence review; final denial followed after closed-account notice.
- Plaintiff sued under ERISA §1132(a)(1)(B); sought benefits, costs, and fees; defendant moved for summary judgment.
- Court applies de novo review because plan did not confer discretion on administrator.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Who bears the burden to prove medical necessity and related exclusions | Baxter contends Regence bears burden to prove not medically necessary. | Regence bears burden only if medical necessity is an exclusion; otherwise plaintiff bears burden. | Burden lies on Plaintiff to prove medical necessity under de novo review. |
| Is proton therapy medically necessary under the Plan language | Proton therapy is medically necessary and superior to IMRT per Plan definitions. | Proton therapy is not medically necessary as it is not superior or cost-effective compared to IMRT per policy. | Proton therapy not proven medically necessary; not covered under the Plan. |
| Is proton therapy more costly than IMRT and thus not covered | Proton therapy should not be presumed more costly; Regence must prove cost superiority. | Proton therapy is more costly than IMRT; evidence shows lack of superior outcomes. | Plaintiff failed to show proton therapy is not more costly than IMRT; no material issue. |
| Are proton therapy and IMRT therapeutically equivalent or is one superior | Evidence suggests proton therapy is superior (fewer/less-severe side effects). | Evidence shows equivalent efficacy; no randomized trials prove superiority. | No genuine issue of material fact that proton therapy is superior; not covered. |
| Breach of fiduciary duty under §1132(a)(3) for equitable relief | Plaintiff seeks equitable relief for denial. | ERISA relief unavailable where other remedies exist under §1132(a)(1). | Dismissed under Varity/Forsyth principles; not cognizable given §1132(a)(1) remedies. |
Key Cases Cited
- Muniz v. Amec Const. Mgmt., Inc., 623 F.3d 1290 (9th Cir. 2010) (burden on claimant under de novo review to prove entitlement to benefits)
- Farley v. Benefit Trust Life Ins. Co., 979 F.2d 653 (8th Cir. 1992) (medical-necessity language treated as coverage description, burden on claimant)
- Juliano v. Health Maintenance Organization of New Jersey, Inc., 221 F.3d 279 (2d Cir. 2000) (burden on plaintiff to prove medical necessity for benefits)
- Boldon v. Humana Ins. Co., 466 F. Supp. 2d 1199 (D. Ariz. 2006) (discussed as not controlling here due to de novo review context)
- Sabatino v. Liberty Life Assurance Co. of Boston, 286 F. Supp. 2d 1222 (N.D. Cal. 2003) (burden allocation in ERISA cases)