Something I found.
Aetna U.S. Healthcare, the insurance carrier for DuPont, denied coverage for the surgery on the ground that there were more conservative and medically appropriate treatments available, such as arthrocentesis or arthroscopic surgery nevertheless went ahead with the arthroplasty surgery and covered the
cost of $9,829.05 herself.
She then brought suit against DuPont in federal district court.
The court found that the record before the administrator (Aetna) and, on appeal to the DuPont Medical Care Plan, supported the denial of coverage for Stratton's TMJ surgery. Stratton appealed, contending, among other things, that Aetna had paid insufficient attention to her claim.
The circuit court found that the record was "detailed and comprehensive" and that DuPont and Aetna "took many steps" in considering Stratton's claim, from inviting additional information and medical history by Stratton and her previous treating physician to reviewing the TMJ post-operative report and having three physicians, one of whom was not involved in the original decision, review the information submitted before finally denying Stratton's request.
As the appellate court observed, Stratton had not previously attempted either arthrocentesis or arthroscopic surgery, both of which are less invasive treatments than the arthroplasty she chose to undergo and both of which Aetna physicians had recommended in lieu of the arthroplasty. The Third Circuit then pointed out that it was not its role to decide which of the three procedures was best tailored to Stratton's case, and declared that "a review of the record shows that DuPont acknowledged and considered that the more conservative treatments had not worked for Stratton in the past and that its suggestion that she undergo less invasive procedures was not based on oversight."
Finally, the circuit court rejected Stratton's argument that Aetna, DuPont, and the district court had failed to accord sufficient deference to the opinion of her treating physician, who had recommended the arthroplasty. As the Third Circuit pointed out, last year, the U.S. Supreme Court, in Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003), held that "plan administrators are not obliged to accord special deference to the opinions of treating physicians." It concluded that Aetna's physicians had not arbitrarily refused to credit Stratton's doctor's opinion but simply had disagreed with his recommended treatment. Accordingly, the appellate court affirmed the trial court's decision in favor of DuPont. [Stratton v. E. I. DuPont de Nemours & Co., 363 F.3d 250 (3d Cir. 2004).]
Comment: A court that scrutinizes a coverage decision by a plan administrator should have a great deal of information to review. Decision makers therefore must ensure that their files are complete and that their decisions are carefully reasoned and explained. If a dispute does reach court, the administrator will seek to have the court decide that the denial of benefits was "supported by the evidence in the record."
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So yup, just like I've read somewhere before, it goes around 10K.
Saving 
