Logan Barrowers v. Aetna Health of California, In

MEMORANDUM

Logan Barrowes appeals the district court’s order affirming Aetna’s denial of coverage for surgery to remove a brain tumor. Because Aetna abused its discretion in concluding that the surgery was not an “emergency service” covered by the plan, Kearney v. Standard Ins. Co., 175 F.8d 1084, 1089 (9th Cir.1999) (en banc), we reverse.

The plan provides that out-of-network emergency services are covered if “the Member’s symptoms were such that a prudent layperson, possessing average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the Member’s health.” Barrowes was told by doctors who examined him in a hospital in Irvine, California, that he had a tumor in his brain that could rupture and blind or kill him if he did not have it removed immediately. A prudent layperson, given this information, would certainly think that he needed to arrange for surgery as quickly as possible.

Aetna argues that Dr. Duma, an in-network neurosurgeon, could have provided immediate medical attention. That is clearly not so. Dr. Duma was definitely not available to consult over the Labor Day weekend. Given…