## Facts

- Grace R. Fuja, a 37-year-old employee-beneficiary, had group health coverage under a plan insured by Benefit Trust Life Insurance Company.
- After breast cancer treatment and remission, she developed metastatic disease in her lungs in 1992 and underwent additional standard-dose chemotherapy.
- Her oncologist recommended high-dose chemotherapy with autologous bone marrow transplantation (HDC/ABMT) after concluding standard-dose therapy offered a negligible chance of survival.
- The proposed HDC/ABMT was to be administered at a hospital under a Phase II clinical protocol.
- Fuja signed an informed-consent document describing the treatment as involving research and experimental aspects.
- The plan defined “medically necessary” care to exclude services “furnished in connection with medical or other research.”
- Benefit Trust denied coverage, concluding HDC/ABMT for Fuja fell within the research-related exclusion.
- Fuja sued under ERISA seeking declaratory and injunctive relief compelling coverage; the district court enjoined Benefit Trust from denying coverage.
- Benefit Trust paid for the treatment under the injunction; Fuja later died, and her husband continued the action as personal representative of her estate.

## Issues

1. Whether the appeal was moot because the insurer had already paid for the treatment ordered by the district court’s injunction.
2. Whether, under the plan terms, HDC/ABMT administered under a Phase II protocol was excluded from “medically necessary” coverage as care furnished in connection with research.
3. Whether ERISA’s standard of review required deference to Benefit Trust’s benefit determination and precluded the district court from ordering coverage contrary to the plan’s terms.

## Decision

- The Seventh Circuit held the case was not moot despite payment, because the judgment and injunction had continuing legal effect and the insurer remained aggrieved.
- The court reversed the district court’s judgment and dissolved the basis for the injunction compelling coverage.
- The court concluded the requested HDC/ABMT was furnished in connection with research and therefore did not meet the plan’s definition of “medically necessary.”
- The court held Benefit Trust’s denial was consistent with the plan language and could not be overridden based on the treatment’s potential promise or the claimant’s medical need.

## Legal Principles

- ERISA benefit disputes are resolved primarily by enforcing the plan’s terms as written when the language is clear.
- When a plan defines “medically necessary” services to exclude care furnished in connection with medical or other research, treatment provided pursuant to a clinical trial protocol falls within the exclusion.
- A court may not rewrite plan coverage based on equitable concerns or a broad, noncontractual conception of medical necessity.
- An insurer’s benefit determination consistent with unambiguous plan language should be upheld under ERISA review principles, even in severe or terminal medical circumstances.

## Conclusion

The Seventh Circuit reversed an injunction requiring coverage for HDC/ABMT, holding that because the treatment was delivered under a Phase II research protocol and characterized as research in consent materials, it was excluded from “medically necessary” benefits under the ERISA plan’s research-related exclusion.


Fuja v. Benefit Tr. Life Ins. Co., 18 F.3d 1405 (7th Cir. 1994)