Oxford Health Plans, LLC provides health benefit plans primarily in New York, New Jersey, and Connecticut in the United States. The company offers commercial products including large group, small group, individual, and health maintenance organization (HMO), as well as Medicare products to different types of customers. Its product line includes HMO plans, exclusive provider organization (EPO) plans, point-of-service (POS) plans, preferred provider (PPO) plans, indemnity plans, and various plans offered to Medicare beneficiaries. The HMO plans provide comprehensive health care benefits through the company’s participating network providers. Its POS plans combine the benefits of HMO plans with c...
48 Monroe Turnpike
Trumbull, CT 06611
Founded in 1984
The U.S. District Court for the Eastern District of New York Grants Summary Judgment in Favor of Oxford Health Plans Inc
Aug 19 13
The U.S. District Court for the Eastern District of New York granted summary judgment in favor of an Oxford Health Plans Inc. in an action brought by a plan participant for wrongful denial of a coverage claim. The record contained substantial evidence supporting the administrator's determination that the claim was for a treatment that was not medically necessary. Sasha Stern, a minor, suffered from congenital adrenal hyperplasia (CAH), a condition characterized by an enzyme deficiency that results in the inability of the adrenal glands to make certain essential hormones. CAH causes premature rapid growth in children, but results in short adult height. Sasha was treated by endocrinologist Dr. Elizabeth Wallach, who diagnosed her with "precocious sexual development and puberty" in April 2009 when she was 10 years old and diagnosed CAH one month later. Wallach treated Sasha with glucocorticoid replacement therapy and GnRH agonist therapy to suppress central puberty. Stern's father, Daniel Stern, submitted a claim for Sasha's related medical bills to Oxford Health Plans Inc., which administered an ERISA-related health benefits plan that Daniel participated in through his employment. Oxford denied the claim, and after exhausting his administrative remedies, Daniel, representing Sasha, sued Oxford for wrongful denial. Both parties moved for summary judgment. The court concluded the record contained substantial support for Oxford's decision to deny coverage for Sasha's growth hormone replacement therapy (GHRT). The medical literature supported Oxford's determination that the use of growth hormone in children with congenital adrenal hyperplasia was not of proven efficacy and had not received Food and Drug Administration approval. The court found that Oxford presented substantial evidence supporting its position that the use of GHRT not associated with a medical condition for the purpose of increasing height was not considered medically necessary. Oxford presented expert opinion evidence from four physicians, including an independent peer review physician consultant who was certified as an endocrinologist. Moreover, Daniel failed to introduce any evidence to refute Oxford's position. Accordingly, the district court granted Oxford's motion for summary judgment.