Meredith Solomon v. Medical Mutual of Ohio, 411 F. App'x 788

Background

ERISA claimant Solomon sought reimbursement from MMO for cocaine-addiction treatment at Hanley Center.
Hanley was listed as in-network on an outdated First Health network site, which misled Solomon.
The Plan excludes residential treatment and requires medical necessity and MMO pre-approval for inpatient care.
Solomon incurred over $40,000 in charges; MMO paid for two days of acute detoxification but denied remaining days.
The independent external reviewer (Dr. Lukawski) found acute care for two days but not for the remainder, aligning with MMO’s denial.
Solomon exhausted internal appeals, pursued ERISA claim in federal court, and district court granted MMO summary judgment under arbitrary-and-capricious review.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Standard of review for MMO’s benefits decision	Solomon argues de novo review should apply.	MMO contends discretionary authority warrants arbitrary-and-capricious review.	Arbitrary-and-capricious review applies.
MMO’s plan interpretation of inpatient vs residential treatment	Hanley was inpatient; plan covers inpatient under medical necessity.	Hanley is Residential Treatment Facility; plan excludes residential care.	MMO reasonably interpreted Hanley as residential; denial upheld.
Equitable estoppel based on outdated network listing	Website error estops MMO from denying in-network rate.	No duty or ambiguity; estoppel not warranted.	Estoppel rejected; district decision affirmed.
Pre-certification and rate of reimbursement dispute for outpatient treatment	Should have paid in-network rate due to website error.	No coverage for outpatient/in-network due to plan terms and error attribution.	No error in denial; reasoning affirmed.

Key Cases Cited

Haus v. Bechtel Jacobs Co., 491 F.3d 557 (6th Cir. 2007) (standard of review for discretionary plan language; arbitrary-and-capricious review standard applies when discretion exists)
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (Supreme Court 1989) (establishes deferential review when plan grants discretion)
Wulf v. Quantum Chem. Corp., 26 F.3d 1368 (6th Cir. 1994) (discretionary authority; limits on de novo review when procedures followed)
Sanford v. Harvard Industries, Inc., 262 F.3d 590 (6th Cir. 2001) (de novo review when plan procedures violated in denial process)
Wintermute v. Guardian, 524 F.Supp.2d 954 (S.D. Ohio 2007) (de novo review where unauthority body rendered decision in violation of procedures)
Shelby Cnty. Health Care Corp. v. Majestic Star Casino, 581 F.3d 355 (6th Cir. 2009) (even with discretionary language, external-review process supports deference to insurer)
Morgan v. SKF USA Inc., 385 F.3d 989 (6th Cir. 2004) (court defers to administrator’s rational interpretation of plan terms)
Calvert v. Firstar Fin., Inc., 409 F.3d 286 (6th Cir. 2005) (confirms conflict-of-interest considerations in arbitrary-and-capricious review)
Helfman v. GE Grp. Life Assurance Co., 573 F.3d 383 (6th Cir. 2009) (ERISA estoppel and plan-ambiguity limitations in applying estoppel)
Riverview Health Inst. LLC v. Med. Mut. of Ohio, 601 F.3d 505 (6th Cir. 2010) (estoppel analysis and reliance in ERISA context)
Bloemker v. Laborers’ Local 265 Pension Fund, 605 F.3d 436 (6th Cir. 2010) (limits on applying estoppel when plan terms unambiguous)