Weissman v. United Healthcare Ins. Co., et al., 19-cv-10580, (D. Mass. Mar. 8, 2021) (Judge Allison D. Burroughs). A putative class of former patients, who were denied life-saving, quality-of-life maintaining proton therapy cancer treatment, brought a putative class action alleging that UnitedHealthcare and the lead putative class plaintiffs’ employer-based health plans breached their fiduciary duties by wrongfully denying medically necessary proton therapy cancer treatment. Lead class plaintiff, Kate Weissman, and her family were able to come up with over $125,000 to privately pay for medically necessary proton therapy treatment to treat her cervical cancer diagnosis after UHC denied her treatment in 2016. Kate, along with other proton therapy patients—Zachary Rizzuto and Richard Cole—brought this putative class to vindicate their rights under ERISA and for potentially countless others challenging UnitedHealthcare’s application of narrowly-restrictive, flawed, out-of-date internal coverage guidelines to wrongfully deny claims for proton therapy.

On March 8, 2021, the Court denied in full UnitedHealthcare’s motion to dismiss the putative class’ (1) claims for denial of benefits and (2) claims for breaches of fiduciary duty.  The Court concluded that Plaintiffs had plausibly alleged that Defendants acted arbitrarily and capriciously in denying their claims for proton therapy. Order, p. 17. Above and beyond this determination by the Court, Judge Burroughs also made clear that “[n]otwithstanding Defendants’ arguments to the contrary, Plaintiffs have alleged more than just that their requests for pre-authorization for PBRT were arbitrarily and capriciously denied. Rather, they have alleged that UnitedHealthcare has developed and applied the PBRT Policy [UnitedHealthcare’s separate coverage policy] to broadly deny coverage for PBRT, even though it is safe and effective, because it is more expensive than IMRT. . . If these allegations are borne out, § 1132(a)(1)(B)’s remedy of repayment of benefits may turn out to be inadequate, and it would therefore be premature to foreclose the possibility of equitable relief, including an accounting and disgorgement [of UnitedHealthcare’s profits from wrongfully denying PBRT claims].” Order, p. 19 (citations omitted).

Finally, the Court also concluded that “even if Plaintiffs can ultimately prove only that UnitedHealthcare breached its fiduciary duty by impermissibly denying their benefits, it is possible that relief under § 1132(a)(1)(B) would still be insufficient. In other words, it is conceivable that even past due benefits, prejudgment interest, and attorneys’ fees may not put Plaintiffs in the position they would have been in but for UnitedHealthcare’s alleged misconduct.” Order, p. 20.