D. v. Anthem Blue Cross, 713 F.Supp.3d 1159

Plaintiffs Robert D. and his daughter K.D. sued Anthem Blue Cross, seeking benefits under an ERISA-governed health plan for K.D.’s residential mental health treatment at Fulshear Treatment to Transition.
The plan covers medically necessary residential mental health services under specific clinical guidelines, which require proof of acute symptoms, risk of serious harm, and a need for structured 24-hour care.
Anthem denied benefits, asserting K.D.’s condition did not meet plan criteria for medical necessity; these denials were upheld after internal appeal and independent external review.
Plaintiffs challenged the denial, citing letters from K.D.'s prior providers recommending residential treatment and contending Anthem’s process failed to properly address those opinions or explain its reasoning.
Both parties moved for summary judgment on the ERISA benefits claim after Anthem’s motion to dismiss the Parity Act claim was granted.
The court reviewed the administrative record de novo because the plan did not give Anthem discretion over claims decisions.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether Anthem meaningfully engaged with K.D.’s treating professionals’ opinions	Anthem failed to address or credit the opinions of K.D.’s providers supporting residential treatment	Anthem considered and addressed the providers’ opinions, as shown in reviewer notes provided to Plaintiffs	Anthem’s procedure complied with regulations; the court may look to reviewer notes since they were disclosed upon request
Whether the denial was substantively correct (i.e., K.D. met plan criteria for residential care)	K.D.’s behavior and provider letters showed residential care was medically necessary	K.D. lacked acute symptoms, risk of harm, or need for 24-hour care; outpatient treatment sufficient	Anthem’s denial letters inadequately explained why K.D. failed criteria; remand required for further explanation
Whether Anthem relied on a new rationale not timely disclosed to Plaintiffs	Yes; Anthem’s post-hoc reliance on lack of “deterioration” from baseline was untimely	No; denial letters invoked the plan guideline criteria	Court will not consider untimely rationale; Plaintiffs weren’t on notice denial rested on this basis
Whether the record supports an award of benefits or remand	Award benefits due to administrative errors and providers’ support	Denial justified by the administrative record	Remand, not an immediate award of benefits, because evidence on necessity was mixed

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (establishes de novo review standard for ERISA claim denials absent plan discretion)
Black & Decker Disability Plan v. Nord, 538 U.S. 822 (plan administrators not required to defer to treating physicians, but cannot arbitrarily disregard reliable evidence)
Spradley v. Owens-Illinois Hourly Employees Welfare Benefit Plan, 686 F.3d 1135 (requiring adequate notice of reasons for claim denial under ERISA)