American Journal of Law & Medicine

ERISA: denial of benefits on experimental procedure affirmed in Tenth Circuit - Healthcare America Plans, Inc. v. Bossemeyer.

ERISA: Denial of Benefits on Experimental Procedure Affirmed in Tenth Circuit--Healthcare America Plans, Inc. v. Bossemeyer(1)--The U.S. Court of Appeals for the Tenth Circuit affirmed a declaratory judgment entered in favor of a denial of coverage for benefits by Healthcare America Plans, Inc.(2) The court found that high-dose chemotherapy breast cancer treatment was appropriately classified as "experimental" and therefore appropriately denied by the plaintiff's health plan.

Plaintiff Constance Bossemeyer sued defendant Healthcare America, the administrator of a group health plan.(3) Under the Employee Retirement Income Security Act (ERISA),(4) the group health plan is an employee welfare benefit plan, and the defendant, because it exercises discretion over the administration of the plan, is a fiduciary under ERISA. The terms of the plaintiff's health care coverage are described in a Certificate of Coverage, which provides that "medical, surgical [and] psychiatric procedures, organ transplants, and pharmacological regimens ... which are considered to be experimental" are not covered by the plan.(5) Experimental is defined under the plan as "those procedures and/or treatments that are not generally accepted by the medical community."(6)

Following plaintiff's diagnosis of breast cancer, she underwent surgery and standard-dose chemotherapy treatment, all covered by Group Health Plan. …

Log in to your account to read this article – and millions more.