Shah v. Secretary of Health & Human Services

Seventy-seven-year-old Rajumati Shah (plaintiff) had healthcare benefits through the Medicare Advantage program. The program allowed an individual to receive Medicare benefits via a privately managed care plan providing access to in-network providers preselected by the plan administrator. Shah’s plan was administered by Health Net of Arizona (Health Net). The provider agreement stated that the plan would cover the costs of out-of-network services only if they were for a medical emergency, urgently needed care, renal dialysis, or care preapproved by Health Net. In 2007, Shah visited India. While there, her knee locked up, causing severe pain. She saw local doctor Bharat Mody, who recommended a knee replacement. Because of Shah’s ongoing health issues, Mody would not perform the procedure until he received Shah’s medical records. The records arrived 10 days later, and Shah had the surgery. She remained in an Indian hospital for two months for physiotherapy. Shah paid $6,801 for her treatment and subsequently submitted a reimbursement claim to Health Net. Health Net denied the claim because Shah’s out-of-network treatment was not considered urgent. At a hearing before an administrative-law judge (ALJ), Shah presented a letter from Mody stating that it was not feasible to send Shah back to the United States for treatment because of her severe pain, her poor general health, and the necessary air travel. Two witnesses for Health Net testified that the 10-day treatment delay while waiting for medical records undermined any claim that Shah’s treatment was truly urgent or addressed a medical emergency. They also explained that other treatment options were usually attempted before resorting to a total knee replacement. The ALJ upheld Health Net’s denial of coverage. Shah sued the secretary of health and human services (defendant) in federal court to challenge the ALJ’s decision.