Health insurance coverage under a plan governed by the Employee Retirement Income Security Act (ERISA); Whether defendant’s denial of coverage was “arbitrary & capricious”; Whether defendant considered “all relevant evidence” when denying coverage; Claim for violation of the Mental Health Parity & Addiction Equity Act (Parity Act)

The court vacated summary judgment for defendant-Anthem Blue Cross and Blue Shield on plaintiff-T.E.’s ERISA claim for health insurance coverage denial, holding that Anthem’s decision to deny coverage was “arbitrary and capricious.” But it affirmed as to T.E.’s Parity Act claim. T.E.’s son, C.E., had mental health issues and T.E. placed him in a long-term, residential-treatment center. Anthem paid for the first 21 days, but then denied continued coverage, contending that the “treatment was no longer medically necessary.” T.E. sued alleging that Anthem’s decision was arbitrary and capricious under ERISA and violated the Parity Act. The district court granted Anthem summary judgment on both claims. On appeal, the parties agreed that the ERISA claim analysis turned on the MCG Guideline for Residential Behavioral Health Level of Care, Child or Adolescent. The court held that Anthem’s denial “was procedurally arbitrary and capricious” where Anthem failed to consider “‘all relevant evidence’” by ignoring “the opinions of C.E.’s treating clinicians.” In addition, it “selectively reviewed the remainder of the medical-record evidence.” The court found it “cherry-pick[ed] portions of C.E.’s medical records that supported its decision while ignoring adverse evidence in those same records.” Further, it “did not ‘adequately explain[]’ its coverage decision nor its ‘change from an earlier benefits ruling.’” The court found that the “scant explanation Anthem did offer disregards the MCG Guideline, the medical evidence, and its prior assessment of C.E.’s need for treatment at” the treatment center. As a result, the court held that the district court erred in granting Anthem summary judgment on the ERISA claim. It remanded “to the district court with instructions to remand to Anthem for further assessment of T.E.’s coverage request.” The court upheld summary judgment for Anthem on T.E.’s Parity Act claim, concluding T.E. failed “to identify record evidence supporting essential elements of that claim.”