By Elise Hansen – Law360
(August 7, 2019) — DLA Piper and Anthem wrongly denied a DLA Piper plan beneficiary’s insurance claim for oral surgery, the man told a Massachusetts federal court Wednesday. Jamesy Jean-Michel, a dependent beneficiary of a DLA Piper plan member, said the surgery for an “aggressive degenerative jaw tissue disease” should have been covered by the firm’s benefits plan but that his claim was wrongly denied and he was jilted out of a full and fair review.
“The decision to deny Mr. Jean-Michel’s benefits was self-serving, wrongful, unreasonable, irrational, solely contrary to the evidence, contrary to the terms of the plan, and contrary to law,” Jean-Michel’s
complaint said.
Jean-Michel said his condition should count as a “jaw joint disorder” under the terms of the plan. His doctor has said the disease could lead to “the loss of the patient’s jaw bone and surrounding structures including joints and ligaments supporting tissue and teeth,” according to the complaint. Anthem Blue Cross Life And Health Insurance Company took the position that the surgery wasn’t covered because it was a dental procedure and was related to tooth and gum disease, according to the complaint.
Anthem in May 2018 denied a claim for oral surgery and stood firm on appeal in March, Jean-Michel said. The complaint noted that DLA Piper did not appear to have been involved in the decision to deny the claim.
Jean-Michel turned to the law firm, kicking off another round of appeals. The firm acted as a “conduit” for information between the parties but did not seem to take part in decision-making involving the second-level appeal, according to the complaint.
Aside from Anthem’s alleged administrative inefficiencies, which the complaint chronicled in considerable detail, Jean-Michel’s counsel said Anthem’s justification for its stance was inadequate, its conclusion was wrong, and it had failed to provide all the documentation required by law. DLA Piper, as the plan’s fiduciary and the responsible party for monitoring the plan’s implementation, should also be held responsible, the complaint said.
“At no time during the course of Mr. Jean-Michel’s claim and the internal appeals process did DLA Piper exercise its discretionary authority to manage the operation and administration of the plan, or to interpret the terms of the plan,” the complaint said. And while the firm could have delegated that authority to Anthem, it didn’t do so, Jean-Michel said.
He is seeking coverage for his treatment, restitution for amounts he has already paid, penalties for the alleged failures to provide complete documentation, and attorney fees.
Representatives for DLA Piper and Anthem did not immediately respond to requests for comment
Wednesday.
Jean-Michel is represented by Mala M. Rafik and Sarah E. Burns of Rosenfeld & Rafik PC. Counsel information for the defendants was not immediately available.
The case is Jamesy Jean-Michel v. Anthem Blue Cross Life and Health Insurance Company et al., case number 1: 19-cv-11699, in the U.S. District Court for the District of Massachusetts.