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2005AP2643 Summers v. Touchpoint Health Plan, Inc.

By: dmc-admin//June 2, 2008//

2005AP2643 Summers v. Touchpoint Health Plan, Inc.

By: dmc-admin//June 2, 2008//

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Insurance
ERISA

Where a termination of benefits under an ERISA-governed plan was arbitrary and capricious, benefits must be reinstated.

"We hold that the termination decision itself was arbitrary and capricious because Touchpoint's interpretations of the plan were inconsistent. We also are satisfied that Touchpoint's decision was arbitrary and capricious because Touchpoint's termination of benefits decision was made despite the external review agency's finding that the requested treatment met the standard of care and was medically necessary, and despite the external review agency recommending approval for the treatment. We further hold that the second termination letter of December 12, 2002, was arbitrary and capricious, because it did not provide a sufficient and adequate explanation of the reasons for Touchpoint's termination of benefits. As a result, the Summers were not provided with the opportunity for a full and fair review of the termination, which is required by 29 U.S.C. § 1133 and 29 C.F.R. § 2560-503-1."

"Lastly, we hold that, given the inconsistent interpretations of the plan by Touchpoint, as well as the ambiguous policy provisions concerning participation in a clinical trial, the appropriate remedy for the termination of benefits in this case is the reinstatement of benefits forward from the date that the benefits were terminated."

Affirmed.

2005AP2643 Summers v. Touchpoint Health Plan, Inc.

Crooks, J.

Attorneys: For Appellant: Gardner, James W., Madison; Meili, Stephen E., Madison; For Respondent: Dreps, Robert J., Madison; Kubiak, Craig, Appleton; Peterson, James D., Madison; Cahill, Bryan J., Madison

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