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California District Court Deems Independent Review Organization Functional Health Plan ERISA Fiduciary
Hall Benefits Law Link to more items from this source
Sept. 27, 2019

"The plan ... had a clause that guaranteed coverage for medically necessary treatment, but nowhere in the plan did it define 'medical necessity.' Due to this vagueness, the court concluded that [independent medical review (IMR) organization] had discretion in reaching its determination of medical necessity of treatment for the plaintiff's daughter. This discretionary authority established them as a functional fiduciary.' [Josef K. v. California Physicians' Service, No. 18-6385 (N.D. Cal. June 3, 2019)]

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