Pacific Shores Hospital v. UBH, No. 12-55210 (9th Cir. 2014)
Annotate this CasePSH filed suit against the Wells Fargo & Company Health Plan, governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., and UBH, seeking payment for additional days of inpatient treatment for an employee with severe anorexia nervosa. UBH is a third-party claims administrator of the Plan and UBH refused to pay for more than three weeks of inpatient hospital treatment for the employee. The court concluded that UBH did not follow procedures appropriate to the employee's case; materials outside the administrative record should have been considered by the district court in any review of UBH's benefits denial; and, even conducting an abuse of discretion review uninfluenced by any procedural irregularity or conflict of interest - and considering only the record that UBH had before it when it made its benefits determination - the court held that UBH improperly denied benefits to the employee. The court concluded that UBH improperly denied benefits under the Plan in violation of its fiduciary duty under ERISA. Accordingly, the court reversed the district court's judgment holding otherwise.
Court Description: Health Care Law. The panel reversed the district court’s judgment in an action under the Employee Retirement Income Security Act concerning a claims administrator’s refusal to pay for more than three weeks of inpatient hospital treatment for anorexia nervosa. Reviewing for an abuse of discretion, the panel concluded that the claims administrator improperly denied benefits under the ERISA plan in violation of its fiduciary duty. The panel concluded that it need not reach contentions that de novo review was warranted by procedural errors in the benefits denial, that materials outside the administrative record should have been considered by the district court, and that the claims administrator operated under a conflict of interest. The panel held that, even conducting an abuse of discretion review uninfluenced by any procedural irregularity or conflict of interest, and considering only the record that the administrator had before it when making its benefits determination, the administrator improperly denied benefits.
Some case metadata and case summaries were written with the help of AI, which can produce inaccuracies. You should read the full case before relying on it for legal research purposes.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.