Denial Of Benefits Did Not Violate ERISA Or Women’s Health And Cancer Rights Act
Geri S. Krauss and Daniel J. Krauss, wife and husband, are members of an employer-provided health care plan that is governed by the provisions of the Employee Retirement Income Security Act (“ERISA”). Oxford Health Plans administers claims for benefits under the plan.
In April 2003, Geri Krauss was diagnosed with breast cancer. Shortly thereafter, she underwent a double mastectomy and bilateral breast reconstruction surgery. The surgical procedures were performed in a single operative session by two different, unaffiliated doctors, neither of whom was a member of the plan's provider network. Following the operation, Mrs. Krauss received care from private-duty nurses. The Krausses paid for both the surgery and post-operative care themselves and sought reimbursement for those expenses from Oxford. Oxford refused payment for one-fourth of the cost of the breast reconstruction surgery and all expenses incurred for private-duty nursing.
After exhausting available administrative appeals, the Krausses filed this lawsuit, alleging that Oxford's denial of full reimbursement for the bilateral surgery and private-duty nursing care violated the Women's Health and Cancer Rights Act (“WHCRA”), as well as various ERISA provisions. They further alleged that Oxford violated ERISA by failing to make certain required disclosures and failing to respond to various grievances in the manner and time periods set forth by their plan.
The trial court ruled in favor of Oxford on all claims. On appeal, the 2nd Circuit somewhat reluctantly agreed, stating: “Although we are not unsympathetic to the effects on the Krausses of the bureaucratic misadventures to which they were subjected by Oxford, we must, and do, nonetheless affirm.”
Krauss v. Oxford Health Plans, Inc.
The 2nd Circuit Court of Appeals’ jurisdiction includes New York, Vermont and Connecticut.