Opinion ID: 788187
Heading Depth: 2
Heading Rank: 3

Heading: Life-Threatening Condition Exception

Text: 25 Ortlieb also argues United HealthCare was not entitled to summary judgment, because a genuine issue of material fact exists as to whether United HealthCare considered Ortlieb's medical condition as life threatening, an express exception to the Plan's experimental, investigational, or unproven service exclusion. United HealthCare contends the life-threatening exception does not apply for two reasons: (1) Ortlieb's medical records do not establish her medical condition was life threatening, and (2) TPN therapy, as utilized in this case, was not a treatment safe with promising efficacy, part of a clinical study, or performed according to specific research protocol. 26 The district court concluded that, although United HealthCare never expressly stated it considered and rejected the Plan's life-threatening condition exception, Dr. Flick addressed the first required element of the exception by questioning the efficacy of TPN treatment for Ortlieb's medical conditions and by identifying several adverse side effects related to TPN therapy. Moreover, the district court determined the record contained no evidence that Ortlieb's TPN therapy at EHC was provided in a clinically controlled research setting and [used] specific research protocol that meets standard[s] equivalent to those defined by the National Institutes of Health. We agree with the district court's conclusion that United HealthCare's independent medical expert, Dr. Flick, at least implicitly considered and rejected the life-threatening condition exception, and his decision in doing so was reasonable. If Ortlieb's medical condition were life-threatening, which is dubious based on this record, United HealthCare's reliance on Dr. Flick's opinions and on the administrative record is reasonable, and its decision to deny benefits is supported by substantial evidence.