Fourth Circuit Holds that Plan Trustees’ Abused their Discretion in Spinal Surgery Claim Denial

On April 20, 2022, the US Court of Appeals for the Fourth Circuit held, in Garner v. Central States, Southeast and Southwest Areas Health and Welfare Fund Active Plan, that the trustees of the plan had abused their discretion by denying the plaintiff’s spinal surgery claim based on two independent physicians’ review.

Dorothy Garner suffered from back and neck pain for several years. Upon being advised by her neurosurgeon, she performed postural exercises and used medication to manage the symptoms. When her pain worsened, the neurosurgeon she had been working with ordered an MRI, and upon review, recommended surgery to relieve Garner’s symptoms. After Garner received the surgery, she received a letter from the Central States, Southeast and Southwest Areas Health and Welfare Fund Active Plan (the plan), stating that her claim involving the surgery had been denied as having been not medically necessary.

The plan trustees came to this decision based on the independent medical review (IMR) of the claim conducted by a general surgeon. However, the surgeon was not provided with any of the records containing the official MRI report or notes from Garner’s neurosurgeon. After Garner and the hospital filed a second appeal, the plan authorized another surgeon to review the claim. That surgeon received full records, including the MRI and office notes. However, this time, the IMR concluded that the surgery was not medically necessary in part because Garner had not taken any conservative measures other than medication. The trustees denied the claim a third time following an appeal of the IMRs of both physicians.

When the case was originally filed with the District Court, that court ruled that the plan trustees had abused their discretion by failing to engage in a reasoned and principled decision-making process. The Fourth Circuit agreed. Specifically, the plan trustees failed to rely on the IMR of the first general surgeon because they failed to provide him with any of her critical MRI records or doctor’s notes. They also pointed out that the second IMR making the decision in part due to the failure of Garner to exhaust conservative treatment options was errant. For one, the plan terms did not set forth the requirement that conservative treatment options be exhausted before surgical treatment. And second, that IMR did not take note of the fact that Garner had unsuccessfully engaged in postural exercises to relieve her pain.

The Fourth Circuit ultimately found that the plan trustees had failed to give Garner’s claim the reasoned consideration that it deserved. In fact, they had three such chances to adequately review her claim. Although remand is sometimes appropriate in this sort of situation, the Fourth Circuit found that remand would simply send the case back to the trustees to potentially make the same errant review they had made before. As such, the court ruled in favor of Garner and affirmed the District Court’s decision to award benefits to Garner.

This case should serve as a reminder that plan fiduciaries should ensure that they are careful in their review of plan claims. Specifically, they should ensure that they are providing all records to any expert that is called in to review a claim, and they should review claims in a way that is consistent with plan terms.

Garner v. Central States, Southeast and Southwest Areas Health and Welfare Fund Active Plan  »