On Monday, the court granted summary judgment in favor of the defendants in a case brought by Continental Medical Transport LLC against Health Care Service Corporation (doing business as Blue Cross Blue Shield of Illinois) et al. The case was filed in the Western District of Washington and concerned the medical necessity of an inter-continental long range international air ambulance from Lima, Peru to Miami, Florida. The plaintiffs are the providers of the air ambulance.
The patient fell ill while traveling in Peru and received treatment at the Clinica Delgado, which both parties acknowledged was one of the newest and most advanced hospital facilities in South America. According to the opinion, the patient’s condition was fragile, but he was transferred via airplane to Miami, Florida at the behest of his family where he later passed away. While medical evacuation is a covered benefit under the patient’s ERISA plan, the court found, it was subject to medical review and Blue Cross Blue Shield (BCBS) as the third party administrator for the plan denied the charges as not medically necessary.
The court first reviewed whether the ERISA plan had effectively delegated its authority to BCBS for the determination of medical necessity. Under ERISA, plan administrator decisions are reviewed for abuse of discretion, and that standard extends to third party administrators if the authority is delegated. The court noted that the delegation was in writing, with approval of the plans Employee Benefit Committee, and was noted in all plan documents. Once this determination was made, the court reviewed the decision from BCBS for abuse of discretion.
In the review of the decision for abuse of discretion, the court noted that there were three requirements for this plan to provide coverage for aerial transport: “Ground ambulance is not available; the patient’s condition is unstable and requires rapid transport; and, in a medical emergency, transport from one hospital to another is necessary because ‘the first hospital does not have the required services or facilities to treat [the patient’s] condition.’” While agreeing that the first requirement was met, the court noted that the patient’s condition was in fact more stable at the Clinica Delgado than it was during and after transport, as well as noting that there were no services that could have been provided in the United States that were not provided at the Clinica Delgado. While the patient’s family wanted the patient to receive a liver transplant and extra-corporeal membrane oxygenation, which were not available at the Clinica Delgado, the patient was not a candidate for these procedures in the United States either, and in fact the patient received only palliative care once in the United States. Finally, a preference for the patient to be treated in the United States due to language difficulties was not sufficient to make the transfer medically necessary.