Cotten v. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

Cotten v. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

What Happened
A patient sued Blue Cross and Blue Shield of Massachusetts, claiming the health insurance company wrongly denied coverage for a wilderness therapy program. The patient argued the company breached its contract and failed in its duty to fairly handle the claim.

What the Court Decided
The court sided with Blue Cross. The judge found that the insurance plan's language clearly stated that wilderness therapy programs were not covered because they counted as "custodial care" rather than medical treatment. The court also dismissed a separate argument about the company's financial duties, finding it repeated the same basic complaint.

Why This Matters for Workers
This ruling shows that insurance companies can deny coverage for treatments if the plan language explicitly excludes them. Workers should carefully read their health plan documents to understand what is and isn't covered before seeking treatment. If you disagree with a denied claim, you may challenge it, but courts will enforce the plan's written terms. Understanding your coverage limits upfront helps avoid unexpected denials and costs.