Garner v. Cent. States

Garner v. Cent. States

Opinion

WILKINSON, Circuit Judge:

Dorothy Garner filed suit under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1001 et seq., after Central States denied her claim for benefits following spinal surgery. The district court granted summary judgment to Garner, concluding that Central States had abused its discretion by relying on a physician's review of Garner's surgery that took place without the benefit of relevant medical records. We agree with the district court that the plan trustees abused their discretion and we affirm.

For years, Dorothy Garner suffered from back and neck pain. She performed postural exercises such as yoga on the advice of a neurosurgeon, Dr. Henry Elsner, and occasionally made use of [*2]  a pain medication, hydrocodone. Nevertheless, her pain worsened and, following Dr. Elsner's recommendation, she had an MRI taken in January 2019. Upon reviewing the MRI, Dr. Elsner concluded that surgery would help relieve Garner's symptoms and on February 5, 2019, he operated on her at Moses H. Cone Memorial Hospital in Greensboro, North Carolina.

Garner's husband worked for United Parcel Service, Inc., and Garner received health insurance coverage under his plan, Central States, Southeast and Southwest Areas Health and Welfare Fund Active Plan. Nonetheless, shortly after her surgery, Garner received a letter from Central States, denying her claim and leaving her responsible for the approximately $90,000 bill. Central States made this determination pursuant to a provision of the plan stating that covered individuals "shall not be entitled to payment of any charges for care, treatment, services, or supplies which are not medically necessary or are not generally accepted by the medical community as Standard Medical Care, Treatment, Services or Supplies." J.A. 42. As Central States found that Garner's surgery was not "medically necessary," it concluded that Garner was not entitled to [*3]  payment.

Central States came to this conclusion based on an independent medical review (IMR) of Garner's claim, conducted by Dr. Francesco M. Serafini, a physician board-certified in general surgery. But the records that Central States provided Dr. Serafini for his IMR failed to contain either the official MRI report that had led Dr. Elsner to recommend surgery or the office notes from Dr. Elsner that explained this recommendation. Without access to these missing documents, Dr. Serafini concluded that there was no basis in the records provided to justify Garner's surgery, and this conclusion formed the basis for Central States' denial letter.

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