Feb 06, 2012

Case Results

DISCLAIMER: Please note that every case is different and these verdicts and settlements, while accurate, do not represent what we may obtain for you in your case.

Medical Necessity of Orthognathic Surgery

In Toman v. Goldman, Sachs & Co. Medical Benefit Plan, 2004 U.S. Dist. LEXIS 8714 (D. Utah), the Firm represented Hethyr Toman, a woman who had serious jaw alignment problems. Her physicians recommended surgery to correct the problem. Toman had medical benefits through a self funded medical benefits plan sponsored by her employer and administered by United HealthCare ("UHC"). UHC denied coverage for the surgery arguing that it was not medically necessary. However, once we reviewed UHC's internal guidelines and criteria it became evident that, when measured against the criteria, the surgery was medically necessary. Nevertheless, UHC would not pay the claim. The Court ruled that UHC was arbitrary and capricious in denying Toman's claim. Commenting on UHC's failure to give credit to the unrebutted opinions of Toman's treating physicians, the Court stated, "plan administrators . . . may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of the treating physician." The court ordered payment of Toman's medical expenses plus prejudgment interest. You can read the decision by clicking on the Library link on the sidebar

Awarded: $33,934.88 plus prejudgment interest