ation we were able to discover that although the health insurance policy had excluded breast reduction surgery, Mutual of Omaha had previously granted coverage to three of the exact same types of surgery to more senior Mutual of Omaha employees within the past year. Thereafter, our case quickly became a question of whether the healthcare administrator was precluded from denying coverage for breast reduction surgery, when it had granted coverage for the same on three previous occasions. The U.S. District Court held that the plan administrator was precluded from denying the claim, when they had granted coverage in the exact same medical circumstances on three previous occasions. This case is currently on appeal with the Eighth Circuit. The issue that I found most compelling while researching ERISA procedure was the administrative appeal process, and the standard of review to which the U.S. District Court must adhere. The U.S. District Court was required to review a case on appeal, after the exhaustion of administrative remedies, only for an abuse of discretion, so long as discretion had been granted to a plan administrator within the plan. In our suit, the health insurance policy did contain a clause that gave the administrator discretion to interpret and review, therefore our burden of proof was to convince the U.S. District Court judge that the administrator had abused his discretion and denied coverage beyond what the administer believed were the policy guidelines. This is an extremely high burden of proof and essentially gave 95% of the power of review to the administrator, which happened to be a panel of senior Mutual of Omaha employees. This seems to me as if the proverbial wolves were guarding the hen house, by placing the persons who benefit from the denial of a claim in charge of the appeal from a claim that a participant thought was unfair. Since I do not understand the reasoning behind this rule of procedure, I w...
