Roggenkamp v. Morgan Stanley Medical Plan

Background Marc Roggenkamp sued the Morgan Stanley Medical Plan to recover benefits for a two-level artificial disc replacement surgery under the Employee Retirement Income Security Act. Cigna, the plan administrator, denied the pre-authorization request, citing internal guidance that categorized the procedure as experimental. The district court upheld the denial, and Roggenkamp appealed. The court’s reasoning The court reviewed the case de novo for the standard of review and for clear error on factual findings. It affirmed that Cigna did not operate under a conflict of interest because Roggenkamp failed to prove that Cigna both determined eligibility and paid for the benefits. The court reversed the denial of benefits, finding that Cigna abused its discretion by relying on a non-plan document, Medical Coverage Policy No. 0104, rather than the Summary Plan Description. The court held that the district court erred by using a post-hoc rationalization based on the Summary Plan Description that was not asserted during the administrative process, depriving the claimant of the opportunity to respond. What it means going forward The decision requires plan administrators to strictly adhere to the governing plan documents when denying claims and to provide specific reasons that allow claimants to meaningfully respond during the administrative review process.