Schulman v. Group Health Inc.

Plaintiffs coverage under the Group Health insurance plan was limited to “medically necessary” services and excluded cosmetic surgery except reconstructive surgery which is not present here. Following the denial of the requisite preapproval for the surgical procedure and both an adverse internal and external appeal, the surgical procedure was performed. The plaintiff commenced this action seeking reimbursement for the medical expenses of the surgery.

The issue is whether the plaintiff established that the surgical procedure was “medically necessary.” The essence of *93plaintiff’s claim is that…