U.S. Court of Appeals for the Fifth Circuit Opinions
Ariana M. v. Humana Health Plan of Texas
Opinion Date: April 21, 2017
Judge: Stephen Andrew Higginson
Areas of Law: Insurance Law
Plaintiff, a dependent eligible for benefits under the Eyesys Vision Inc. group health plan, filed suit challenging Humana's denial of benefits. The district court ultimately granted summary judgment for Humana. The court found that Texas's anti-discretionary clause does not change the court's normal abuse of discretion deference pursuant to Pierre v. Connecticut General Life Insurance Co./Life Insurance Co. of North America. The court concluded that the district court did not err in finding that Humana's consideration of the Mihalik criteria was proper because the record supported a finding that the Mihalik criteria are in line with national standards. Finally, the court concluded that it was not unreasonable on this record to conclude that plaintiff could be treated with a less costly, equally effective outpatient treatment. Therefore, substantial evidence supported Humana's finding that further treatment for plaintiff at the Avalon Hills facility was not medically necessary. The court found plaintiff's remaining arguments were without merit and affirmed the judgment.
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