A recent decision by a federal district court in Ohio in a health plan benefits dispute highlights the importance for health plan fiduciaries to properly review benefit claim denials to ensure that the claims administrator’s basis for denial is appropriate and that the claims administrator has properly considered information provided by the participant.

In this case, the participant sued after he was denied coverage for more than $100,000 of medical bills related to a broken ankle suffered when he was kicked by his bull calf. Even though the participant worked as an HVAC division manager, the health plan’s third-party administrator denied the claims based on the plan’s exclusion for on-the-job injuries because the participant owned a cattle farm from which he sold beef. The court ruled that the participant was entitled to coverage for his medical expenses because the health plan fiduciaries had the burden of demonstrating the plan exclusion applied.

Neither the employer, who was the ERISA plan administrator, nor the claims administrator gave sufficient consideration to the participant’s assertion that this bull was being raised for personal consumption rather than to be sold. It appears both were dismissive of the participant’s assertion.

While this case involves unusual facts, it emphasizes the importance for health plan fiduciaries to appropriately consider information provided by participants in the claim review process and to ensure that plan exclusions have been applied appropriately to deny claims and appeals. Health plan sponsors that retain responsibility to decide appeals may want to consider implementing a health plan fiduciary committee, if they do not already have one, to review appeals through a consistent process.