Stern v. Oxford Health Plans

U.S. DISTRICT COURT
EASTERN DISTRICT OF NEW YORK
Employment

, New York Law Journal

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Judge Joseph Bianco

Stern is an Oxford Health Plan participant. Oxford both evaluates and pays benefits on claims. Although Oxford's Growth Hormone Replacement Therapy Guideline (GHRT Guideline) states that growth hormones are covered under the Plan, it also states that such therapy is not covered for conditions associated with short stature. It specifically lists congenital adrenal hyperplasia (CAH) as a condition not to be treated with growth hormone therapy under the Plan. Finding Oxford's structural conflict of interest entitled to little weight, district court granted Oxford judgment in Stern's lawsuit asserting its violation of ERISA by denying minor son Sasha with growth hormone therapy treating his CAH. The court pointed out that the Plan, through the GHRT Guideline, explicitly bars coverage for treatment of short stature associated with CAH. Also, Oxford's reviewing doctors—including a board certified endocrinologist consultant—found growth hormone therapy in children with CAH not medically necessary. Further, the FDA does not approve growth hormone for treatment of CAH. Nor did Sasha's treating physician refer to medical studies refuting Oxford's determination that growth hormone treatment has not been proved effective for CAH.

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