Doe v. Deloitte LLP Grp. Ins. Plan, 2025 WL 586670 (S.D.N.Y. 2025)
A participant in an employer sponsored health plan sought a “single case agreement” that would allow plan coverage for his child’s treatment at an out-of-network residential mental health facility. While the plan generally did not cover services performed by out-of-network providers, the plan document set forth procedures for an exception. The participant argued that such an exception was warranted because the plan’s in-network options for the necessary treatment were inadequate; granting the out-of-network facility a single case agreement would allow treatment there to be covered. The plan’s claims administrator denied coverage (both initially and on appeal) due to the facility’s out-of-network status. Because the denial letters failed to address whether to authorize the single case agreement, the court concluded that the decision to deny benefits was arbitrary and capricious and rendered “without reason.”
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