Nystrom v. AmerisourceBergen Drug Corporation
0:13-cv-00557
D. MinnesotaSep 2, 2014Background
- ERISA benefits dispute arising from Nystrom’s treatment under AmerisourceBergen Plan; AmerisourceBergen delegated coverage determinations to Aetna; Nystrom diagnosed with bulimia nervosa, PTSD, major depression, alcohol abuse, Type I diabetes; Timberline Knolls residential treatment denied as not medically necessary; multiple appeals upheld denial; district court grants summary judgment for defendants.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Standard of review for denial of benefits | Nystrom seeks de novo review | Plan grants discretionary review to administrator | Abuse-of-discretion standard applies |
| Whether denial was supported by substantial evidence | Residential care was medically necessary | Record shows medical necessity not met | denial upheld based on substantial evidence |
| Adequacy of investigation by Aetna | Aetna failed to obtain necessary information | Aetna obtained information and communicated reasons | No abuse; investigation adequate |
| Weight given to treating physicians’ opinions | Treating opinions should control | Reviewing physicians’ opinions can control when record supports denial | Substantial evidence supported relying on reviewing physicians |
| Use of LOCAT in decision | LOCAT improperly drove denial | LOCAT used as one tool among rationales | LOCAT reliance not improper; other rationales supported denial |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (Supreme Court 1989) (establishes deference framework for ERISA review when discretionary authority exists)
- Hankins v. Standard Ins. Co., 677 F.3d 830 (8th Cir. 2012) (explicit discretion-granting language supports abuse-of-discretion review)
- King v. Hartford Life & Accident Ins. Co., 414 F.3d 994 (8th Cir. 2005) (discretion to construe uncertain terms triggers abuse-review)
- Midgett v. Wash. Group Int'l Long Term Disability Plan, 561 F.3d 887 (8th Cir. 2009) (treating physicians not automatically controlling; reviewing evidence suffices)
- Ortlieb v. United HealthCare Choice Plans, 387 F.3d 778 (8th Cir. 2004) (plan administrator may rely on delegated determinations; abuse review if discretion granted)
- McGee v. Reliance Standard Life Ins. Co., 360 F.3d 921 (8th Cir. 2004) (substantial evidence standard governs review of benefits decisions)