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Bechtold v. Physicians Health Plan of Northern Indiana, Inc.

United States Court of Appeals for the Seventh Circuit
19 F.3d 322 (1994)


Facts

Penny Jo Bechtold (plaintiff) had healthcare coverage through an employer health plan administered by Physicians Health Plan of Northern Indiana, Inc. (PHP) (defendant). Bechtold was diagnosed with breast cancer. Bechtold’s cancer involved a solid tumor and might have been spreading. Bechtold’s doctors treated the cancer aggressively, which included recommending that she try a type of bone-marrow transplant known as HDC/ABMT that was commonly used to treat some cancers. Although there was still some uncertainty about whether this treatment was effective for solid-tumor cancers like Bechtold’s, Bechtold was 40 years old, and her age made the treatment more likely to be helpful. PHP refused to authorize the treatment because the health plan’s terms considered it experimental. PHP relied on a Medicare manual to determine which treatments were experimental, and the manual stated that there was insufficient evidence that HDC/ABMT was effective for solid-tumor cancers. Bechtold appealed the refusal to a PHP committee. The committee confirmed that the treatment was not covered under the health plan’s current contractual terms. However, the plan’s language gave PHP the right to reconsider which treatments were deemed experimental. The committee recommended that PHP reconsider its position that the HDC/ABMT treatment was experimental in this situation because there was evidence that it was a reasonable way to treat Bechtold. Relying on the plan’s terms, PHP still refused to authorize the treatment. Bechtold received the treatment using an alternate payment source and sued PHP for reimbursement. Bechtold argued that PHP had an obligation to reconsider its position on what was experimental in order to stay current with medical advancements and that PHP had wrongfully ignored the committee’s recommendation to add coverage for the HDC/ABMT treatment in her case. A magistrate denied Bechtold’s motion for summary judgment. The case was appealed to the Seventh Circuit.

Rule of Law

Issue

Holding and Reasoning (Coffey, J.)

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