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ARTICLE · 02 FEBRUARY 2026

Sixth Circuit Implies New Requirements For Denial-of-Coverage Communications

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The 6th Circuit may no longer be as favorable a venue for health plans engaged in legal disputes with members who allege that insufficiently detailed claim denials violate ERISA's protections against "arbitrary and capricious" decision making.

United StatesEmployment and HR
Rebecca Hanson
Rebecca Hanson
Taylor A. Marcusson
Taylor A. Marcusson

What You Need to Know

  • Key takeaway #1 The 6th Circuit may no longer be as favorable a venue for health plans engaged in legal disputes with members who allege that insufficiently detailed claim denials violate ERISA's protections against "arbitrary and capricious" decision making.
  • Key takeaway #2 On January 22, 2026, a 6th Circuit panel characterized a health plan's decision to deny coverage for extended residential behavioral treatment provided to a member's minor son as "arbitrary and capricious" — an ERISA violation — because it lacked specific evidentiary support. This decision echoes similar rulings issued by courts in the 10th and 5th Circuits.
  • Key takeaway #3 The 6th Circuit panel determined that, when issuing denials of coverage based on a lack of medical necessity, claims administrators must explicitly acknowledge and refute treating physicians' recommendations and include direct reference to relevant medical criteria, which is not currently

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