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Bedrick v. Travelers Insurance Company

93 F.3d 149 (1996)

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Bedrick v. Travelers Insurance Company

United States Court of Appeals for the Fourth Circuit

93 F.3d 149 (1996)

Facts

Ethan Bedrick (plaintiff) was enrolled in his parent’s medical-insurance benefit plan funded and administered by Travelers Insurance Company (Travelers) (defendant). The plan was subject to regulations under the Employee Retirement Income Security Act of 1974 (ERISA). As a result of Ethan’s difficult birth, Ethan suffered from severe cerebral palsy and spastic quadriplegia and received coverage for speech therapy, physical therapy, and occupational therapy under the plan. However, when Ethan was 14 months old, Travelers informed the Bedricks that it would no longer cover speech therapy and severely limited his physical- and occupational-therapy coverage. Ethan was nonverbal at the time. The company also informed the Bedricks that it would not cover the upright stand that they had requested, which would help Ethan stand and prevent further injuries. The company claimed that the plan’s restriction to medically necessary care gave it discretion to determine whether a service was medically necessary. The company explained that it had concluded Ethan’s therapies were not medically necessary, because they were unlikely to lead to significant progress for Ethan. However, the provision restricting service to medically necessary care did not include a significant-progress requirement. The plan did include a provision that speech therapy would be covered if needed to restore speech. Ethan’s physician and therapists opposed the decision. Ethan’s parents, on Ethan’s behalf, sued Travelers. The lawsuit was removed to federal district court and characterized as an ERISA claim. Ethan’s parents sought the services they had requested. The district court granted summary judgment in Travelers’ favor. The Bedricks appealed.

Rule of Law

Issue

Holding and Reasoning (Hall, J.)

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