Alexandra H. v. Oxford Health Ins., No. 15-11513 (11th Cir. 2016)Annotate this Case
Plaintiff filed suit under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., seeking benefits for continued partial hospital treatment for her anorexia, which were denied on the ground that the level of care she sought was not medically necessary. On appeal, plaintiff challenged the district court's grant of summary judgment for Oxford. After careful consideration of the parties’ briefs, the record in the case, and with the benefit of oral argument presented to the court, the court concluded that the district court correctly decided that the record of the external review is properly before the district court in this ERISA case. However, the court concluded that the district court erred in holding that the adverse external review decision barred plaintiff from presenting her challenge to the adverse medical necessity determination. Because the external review process does not conflict with ERISA, it is not preempted. Accordingly, the court affirmed in part, reversed in part and remanded for further proceedings.