Rush Prudential HMO, Inc., v. Debra C. Moran, et al.

Facts

Debra C. Moran (Plaintiff) is a beneficiary of an employee welfare benefit plan provided by Rush Prudential HMO, Inc. (Rush) (Defendant) and sponsored by her husband's employer. In 1996, Plaintiff began to experience pain and numbness in her right shoulder. Her primary care physician, Dr. LaMarre, administered conservative treatments without success. In October 1997, Dr. LaMarre recommended that Defendant approve surgery by Dr. Terzis, an unaffiliated specialist who had developed an unconventional treatment for the condition Plaintiff suffered with. Defendant denied the request, in spite of Dr. LaMarre's assurances that this was the best treatment for Plaintiff. Defendant suggested that Plaintiff have standard surgery performed by a Rush-affiliated doctor. In January 1998, (Plaintiff) made a written demand for an independent medical review of her claim. Defendant did not provide an independent review, and Plaintiff filed a state court action demanding compliance with a state HMO Act providing a right to independent medical review of certain denials of benefits. Defendant removed the claim to federal court, arguing that a cause of action was completely preempted under ERISA. Plaintiff had the surgery by Dr. Terzis while her suit was pending, at her own expense, and submitted a claim to Defendant for reimbursement of $94,841.27. Defendant began a new inquiry to determine coverage. The federal court remanded the case to a state court, which enforced the state statute. The doctor chosen for the independent review found the treatment was medically necessary, but Defendant continued to deny Plaintiff's claim for coverage. The Seventh Circuit Court of Appeals reversed.