Law360 (November 19, 2024, 7:42 PM EST) — A Florida federal judge on Tuesday refused to toss a federal benefits lawsuit from a patient who alleged that UnitedHealthcare wrongly denied him coverage for proton beam therapy to treat tongue cancer, rejecting the insurer’s argument that an exclusion for unproven treatments applied.
U.S. District Judge Cecilia M. Altonaga entered an order denying UnitedHealthcare Insurance Co.’s motion to dismiss Carlos Morera’s Employee Retirement Income Security Act suit for failure to state a claim. Morera first sued in July, seeking to recover the approximately $195,000 he paid out of pocket for proton beam radiation therapy, or PBRT, to treat a rare squamous cell carcinoma at the base of his tongue after being diagnosed in September 2023, according to his complaint.
Morera alleged that the treatment should have been covered under the terms of his wife’s employer-provided group healthcare plan, of which he was a beneficiary and which was insured and administered by UnitedHealthcare, the complaint said.
Judge Altonaga said in her order Tuesday that Morera’s complaint contained enough evidence to state a claim under ERISA that UnitedHealthcare wrongly denied benefits that were medically necessary and should have been covered under the terms of his plan.
Furthermore, at the motion to dismiss stage, UnitedHealthcare had the burden to demonstrate that an exclusion under the plan for “unproven services” applied, if the insurer wanted to assert that argument as an affirmative defense, Judge Altonaga said.
“Pleading specific ‘trials’ or ‘studies’ and rebutting the affirmative defense of exclusion are simply not required [from Morera],” Judge Altonaga said.
Judge Altonaga said in a footnote that while some judges in Florida’s Southern District disagreed on whether insurance policy exclusions could be used as an affirmative defense, “the case law reflects that defendants bear the burden to prove exclusions that divert from a list of covered services.”
Morera’s radiation oncologist had recommended PBRT over other cancer treatments because of the position and complexity of his tumor, Judge Altonaga said in a portion of her order describing the facts of the case. The oncologist had also recommended the treatment because PBRT reduced radiation to his other vital organs, such as his brainstem and esophagus, Judge Altonaga said.
Judge Altonaga said that factual disputes about the effectiveness of the radiation therapy and “the merits of PBRT’s potential exclusion under the plan” were merits arguments for consideration during summary judgment or trial.
“Plaintiff need not support the complaint’s allegations with items of proof,” Judge Altonaga said.
When asked for comment on the decision, Morera’s attorney Stephanie A. Casey said Tuesday, “We look forward to presenting the merits of this case at trial.”
“Proton beam radiation therapy has long been recognized as the standard of care for the treatment of head and neck cancers,” Casey said.
Counsel for UnitedHealthcare and a company spokesperson didn’t immediately respond to requests for comment Tuesday.
Morera is represented by Stephanie A. Casey of Colson Hicks Eidson.
UnitedHealthcare is represented by Allen P. Pegg, Robert C. Leitner and Jordan D. Teti of Hogan Lovells.
The case is Morera v. UnitedHealthcare Insurance Co., case number 1:24-cv-22814, in the U.S. District Court for the Southern District of Florida.
–Editing by Leah Bennett.
