Jones v. The Kodak Medical Assistance Plan

Russell Jones and Susan Jones (plaintiffs) were enrolled in the Kodak Medical Assistance Plan (the plan) (defendant) through Russell’s employment. The plan’s summary provided that all mental-health and substance-abuse treatment had to be precertified as medically necessary. The plan further provided that the plan administrator had full authority to establish coverage criteria and determine whether an enrollee satisfied the criteria. In 1993 the Joneses attempted to obtain inpatient alcohol-abuse treatment for Susan at Sierra Tucson Hospital in Arizona. The hospital contacted the plan administrator to obtain the precertification. The plan administrator denied precertification because Susan had failed to meet the necessary criteria to constitute requiring medically necessary treatment and because the treatment program was located out of state. Susan’s condition further deteriorated, and the Joneses appealed the plan administrator’s decision. Pursuant to the appeal, the plan administrator consulted with an independent reviewer. The reviewer agreed that Susan did not meet the criteria but stated that the criteria were too strict. The plan administrator reaffirmed the decision. The Joneses filed an action against the plan in federal district court on the ground that the plan administrator had acted arbitrarily and capriciously and that the Employee Retirement Income Security Act of 1974 (ERISA) required the plan administrator to disclose the treatment criteria that the plan administrator had used in the assessment. The plan moved for summary judgment. The district court granted the motion on the grounds that the Joneses had failed to demonstrate that the administrator acted arbitrarily and capriciously, that ERISA did not require the plan administrator to disclose the criteria used, and that the court did not have judicial authority to review the criteria used. The Joneses appealed to the United States Court of Appeals for the Tenth Circuit.