Doe v. Group Hospitalization & Medical Services
United States Court of Appeals for the Fourth Circuit
3 F.3d 80 (1993)
John Doe (plaintiff), a law firm partner diagnosed with a fatal blood cancer, sought coverage from his employer's insurer, Blue Cross (defendant), for chemotherapy, radiation, and a bone marrow transplant. Blue Cross had mailed a notice amending the group plan to exclude bone marrow transplants and services "related to" them, and it denied Doe's entire claim, including the chemotherapy and radiation, on that basis. Doe sued under ERISA, arguing the notice was untimely or misleading and that Blue Cross, which pays claims from its own funds, had a financial incentive to deny coverage. The district court granted summary judgment for Blue Cross.
Whether a court must be as deferential to a fiduciary's interpretation of a disputed contract term when that interpretation financially benefits the fiduciary as it would be absent such a conflict of interest.