Doe v. Group Hospitalization & Medical Services

John Doe (plaintiff), a law firm partner, was diagnosed with a rare and typically fatal form of blood cancer. Doe’s physician, Dr. Anderson, prescribed a course of chemotherapy treatment which reduced Doe’s number of cancerous cells. Anderson then recommended that Doe undergo a high-dose chemotherapy and radiation therapy combined with a bone marrow transplant. The cost of the treatment was estimated at $100,000. Doe sought health insurance benefits for the treatment from the law firm’s insurance provider, Group Hospitalization and Medical Services, Inc., doing business as Blue Cross and Blue Shield of the National Capital Area (Blue Cross) (defendant). Several months before Doe’s request, Blue Cross had sent a letter to all of its group insurance contracts, including the law firm, informing them of coverage changes and updates. Blue Cross relied on the letter when it denied Doe’s request, noting that the amended contract excluded benefits for bone marrow transplants and “related” services. Doe and the law firm filed suit against Blue Cross under § 502 of the Employee Retirement Insurance Security Act (ERISA), 29 U.S.C. § 1132. Doe claimed that the denial of benefits was improper because Blue Cross had not complied with the requirements for providing timely notice to its providers regarding the changes and even if it was timely, the amendment language was misleading. The district court granted Blue Cross’s motion for summary judgment and Doe appealed.