Mondry v. American Family Mutual Insurance Company

Sharon Mondry (plaintiff) and her son were enrolled in a health plan governed by the Employee Retirement Income Security Act of 1974 (ERISA) and administered by American Family Mutual Insurance Company (AF) (defendant). AF contracted with Connecticut General Life Insurance Company (CIGNA) to make coverage decisions. In July 2003, Mondry was informed that based on CIGNA’s guidelines, her claim for her son’s speech therapy was denied because it constituted educational or training services rather than restorative services. Mondry requested the production of the documents in which the guidelines were provided. AF and CIGNA denied the request. The decision to deny was affirmed by an internal appeals process. In October 2004, after multiple document requests, CIGNA provided the two documents it had cited: the Clinical Resource Tool for Speech Therapy (CRT) and the Benefit Interpretation Resource Tool for Speech Therapy (BIRT). Mondry pursued a second-level appeal for coverage. CIGNA concluded that Mondry’s claim had been improperly denied and reversed the denial without any explanation. Mondry was reimbursed for the speech therapy, except for the $303 out-of-pocket expense she had paid after discontinuing her participation in AF’s plan. Mondry filed an action in federal district court against AF and CIGNA for violating ERISA and breaching their fiduciary duty. Mondry also sought reimbursement for the $303. The district court granted AF summary judgment. Mondry appealed.