United States District Court, E.D. Wisconsin
DECISION AND ORDER
WILLIAM E. DUFFIN, U.S. Magistrate Judge.
John and Sal Sendik (Sal is John's son) filed the present
action against Cigna Health and Life Insurance Company,
Massachusetts Mutual Life Insurance Company, and MassMutual
Agents' Welfare Benefits Plan to claim dental benefits
under an ERISA-governed, self-funded, high-deductible health
insurance plan. The plan, MassMutual Agents' Welfare
Benefits Plan 506, was sponsored by John Sendik's
employer, Massachusetts Mutual Life Insurance Company, and
administered by Cigna Health and Life Insurance Company. The
court has subject matter jurisdiction under 28 U.S.C. §
1337 and 29 U.S.C. § 1132(e).
Sendik was diagnosed with odontodyslplasia/odontogenesis
imperfecta (ECF No. 1, ¶ 9), a congenital abnormality in
the development of the teeth (ECF No. 30 at 2, fn. 3). He
sought treatment from Dr. Christopher P. Sobczak, M.D., Dr.
Benjamin S. Fiss, D.D.S., and Dr. Daniel M. Weber, D.D.S.,
M.S. (Id. at ¶ 10.) The Sendiks were billed
$67, 347 for the treatment. (Id. at ¶ 11.) The
Sendiks requested that defendants cover the costs of the
treatment, defendants denied coverage, and the Sendiks
appealed. (Id. at ¶¶ 12-14.)
defendants upheld their original decision denying coverage
for the treatments on the ground that the plan
“provides benefits only for covered expenses for
treatment or diagnosis of an injury or illness” and,
“[a]ccording to MassMutual Financial Group coverage,
your plan does not cover surgical removal of erupted tooth
requiring elevation of mucoperiosteal flap and removal of
bone and/or section of tooth.” (ECF No. 28 at 171.)
Sendiks filed a separate appeal and noted that:
Patient was born without teeth. Diagnosis of odontodysplasia
was made by pediatrician - supported by letter from Dr.
Chrostopher Sobczak. Surgery was needed so patient could eat.
This bill was not included in original appeal. This was
necessary surgery and restoration. Necessary to be able to
(ECF No. 28 at 222.) The second appeal was denied on the
ground that the services were for surgical treatment to
remove impacted teeth, which is not covered under the plan.
(Id. at 225.) Additionally, according to the plan
Not Covered (not all-inclusive):
Your plan provides coverage for most medically necessary
services. Examples of things your plan does not cover, unless
required by law, include (but aren't limited to):
Dental implants for any condition.
(ECF No. 28 at 225-26.)
Sendiks allege that the denial was arbitrary and capricious
did not have all relevant medical records in their
possession, had not discussed Sal's medical condition and
treatment with all of Sal's treating physicians and
specialists, did not consider the severity and totality of
his condition, did not consider that the care provided by
Sal's doctors was based upon recognized standards of
health care for the treatment of
odontodysplasia/odontogenesis imperfecta, and failed to