Anthem Faces ERISA Suit Over Denial of Benefits for Rare Pediatric Condition

A Missouri man has brought suit against defendants Anthem Blue Cross and Blue Shield (Anthem), Ameren Corporation, and Ameren Services Company for their supposed breach of statutory, contractual, and fiduciary obligations and violation of the Employee Retirement Income Security Act of 1974 (ERISA). Allegedly, the plaintiff’s minor son received treatment for a rare pediatric disorder for which the defendants unfairly declined to pay.

Monday’s complaint alleged that the plaintiff is an Ameren Corporation employee who receives Anthem health care coverage for himself and his family through the company’s group insurance policy. The filing further stated that Ameren Corporation is the plan sponsor and payor while Ameren Services Company is the plan administrator.

The ERISA complaint set forth the facts leading up to the dispute, starting with the plaintiff’s son’s diagnosis of Autoimmune Encephalitis (AE) in 2014. AE reportedly is a rare condition wherein the body’s immune system mistakenly assaults healthy brain cells, causing inflammation of the brain. The plaintiff’s son was diagnosed with several other conditions in subsequent years, including an immune deficiency.

According to the complaint, one of the treatments the son received for AE was high dose intravenous immunoglobulin (IVIG), to which he initially responded well. Yet, allegedly, IVIG became less effective over time, leading to “frequent relapses of varying intensity culminating with (his) suicidal thoughts in February of 2018.”

The son’s physicians tried another treatment, a drug called rituximab, in summer 2018, which quickly improved his mental and physical health above baseline levels, the filing stated. Though allegedly Anthem originally signaled it would pay for rituximab, it ultimately denied the claim. Anthem reportedly did so on the basis that the treatment was not “medically necessary,” and, therefore, fell outside coverage because AE was not listed as one of the conditions that rituximab is prescribed to treat.

After two appeals, the plaintiff filed the instant lawsuit, claiming that the decision to deny coverage was wrongful. The complaint stated that in making its determination, Anthem improperly relied on the views of two physicians who were not qualified to opine about the treatment of AE.

In addition, the plaintiff contended, Anthem did not indicate it gave due consideration to peer-reviewed articles supporting the use of rituximab in the treatment of AE submitted by the son’s treating physicians on appeal. Finally, the plaintiff claimed that the Anthem decisionmaker wrongly denied his request that the claim be reviewed by a board certified specialist in pediatric neurology and neurodevelopmental disabilities.

The two-count complaint seeks the recovery and payment of benefits under the plaintiff’s plan, statutory penalties, and the complainant’s litigation costs and attorneys’ fees.

The plaintiff is represented by Gallagher Davis LLP.