Blue Cross Blue Shield of South Carolina (BCBS SC) and Companion Benefit Alternatives, Inc. aren’t the proper defendants in a woman’s case for wrongful denial of benefits concerning her detoxification and depression treatments.
Helene M. Smith filed suit against the defendants, and the U.S. District Court in the Middle District of Florida’s Jacksonville Division, via U.S. Magistrate Judge James R. Klindt, dismissed the case.
“Upon review, the court determines that dismissal is appropriate and necessary because Blue Cross Blue Shield of South Carolina and Companion Benefit Alternatives, Inc. are not proper defendants,” wrote Justice Klindt. The defendants argued that Smith should have disputed her coverage with her employer, who is the true plan administrator.
The Employee Retirement Income Security Act of 1974 (ERISA) says the proper defendant in a benefits lawsuit is the administrator of the plan. In this case, it would be Smith’s employer, Nelson Mullins Riley and Scarborough, LLP. Even though one portion of the plan says that BCBS SC has the role, additional clauses and the Summary Plan Description point to Smith’s employer as the plan administrator.
“Importantly, the plan specifically defines Plan Administrator as the employer (Nelson Mullins), and the Claims Administrator is defined as BCBS SC,” wrote Judge Klindt. “In other plan provisions, Nelson Mullins is again identified as the Plan Administrator.”
At the same time, the plan doesn’t detail that the defendants are in the position to manage the administration plan or make decisions concerning it. While the defendants can decide if a healthcare service is considered medically necessary, that’s only a portion of the total requirements taken into account when it comes to coverage qualification.