Birdsell v. United Parcel Service of America, 94 F.3d 1130 (8th Cir. 1996) - Participant brought action to recover dental benefits which his employer denied. The summary plan description specifically provided that dental implants were not covered unless pre-approved. Plaintiff's dentist favored the implants, and sent medical information to the insurer (Aetna) to review and to determine whether the implants were medically necessary. Aetna consulted with 2 other dentists and one oral surgeon all of whom agreed that conventional dentures were appropriate and implants were not medically necessary. Aetna informed plaintiff of its decision to deny coverage, however, plaintiff proceeded to obtain the implants without prior consent. When he made a claim for benefits, he alleged that conventional dentures caused him constant pain and made eating solid foods impossible. When Aetna again denied the claim, plaintiff's counsel wrote a letter requesting numerous documents relating to the denial. Aetna treated the letter as a request for an appeal, and responded that the appeals committee conducted a thorough investigation and found no evidence to override Aetna's denial decision. It enclosed some of the requested documents and explained the rest would be delivered upon receipt of payment for copying costs. On appeal from summary judgment to the defendant, plaintiff argued that he was denied full and fair review of his claim because Aetna failed to conduct an independent clinical analysis of his condition, failed to obtain his full medical record and failed to adequately explain the reason for the denial. Addressing each argument in turn, the Eighth Circuit found that this was not a case where an independent examination was necessary. Aetna's dentists had all of the relevant medical evidence to determine whether implants were necessary. They simply reached a different conclusion than plaintiff's dentist. Plaintiff failed to prove that they would have reached a different conclusion had they examined him personally. Next, they rejected the argument that Aetna did not have plaintiff's full medical record. Plaintiff had ample opportunity to provide Aetna with all of information he believed would support his claim, but failed to do so. Furthermore, plaintiff's dentist stated that he provided Aetna with "all of the necessary information." Finally, the court found that Aetna provided a sufficient explanation for its denial decision by explaining to plaintiff that coverage was denied because three dental consultants concluded that implants were not medically necessary and conventional dentures were a workable alternative. Thus, the court concluded that plaintiff received a full and fair review. In a brief statement, the court found no merit in plaintiff's claim for statutory penalties under § 104(b)(4) and found no reason to remove the trustee since there was no violation of fiduciary duty.