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Sendik v. Massachusetts Mutual Life Insurance Co.

United States District Court, E.D. Wisconsin

January 8, 2018

JON SENDIK AND SAL SENDIK, Plaintiffs,
v.
CIGNA HEALTH AND LIFE INSURANCE COMPANY; MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY; AND MASSMUTUAL AGENTS WELFARE BENEFITS PLAN HDHP, Defendants.

          DECISION AND ORDER

          WILLIAM E. DUFFIN, U.S. Magistrate Judge.

         Plaintiffs 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).

         I. Facts

         Sal 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.)

         The 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.)

         The 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 chew.

(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 booklet:

         What's 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.)

         The Sendiks allege that the denial was arbitrary and capricious because defendants

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 ...

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