• Filing. Filed in U.S. District Court for the District of Utah on January 17, 2020 (Case no. 2:17-cv-01328-DAK).
  • Background.  Parents bring action on behalf of their daughter who suffers from a number of mental health issues including suicidal ideation.  D.K., one of the parents, was an employee with a self-funded health plan administered by UBH.  UBH determined that daughter’s treatment was 1) not consistent with generally accepted standards of medical practices; 2) experimental; and 3) not clinically appropriate.  Appeal 1 upheld the denial of care.  Appeal 2 upheld original denial but the UBH letter contained new justifications for denying the daughter coverage:  1) treatment at the residential treatment facility (Discover) was not medically necessary under the terms of the plan; 2) the daughter’s symptoms were in remission; and 3) her mental health needs could be treated at a lower level of care.  At external review, the denial was upheld because the care was not medically necessary under the terms of the plan.

The Plan defined “Medically Necessary” as the “determination by the Claims Administrator, at its discretion, that a service or supply is medically necessary appropriate for the diagnosis or treatment of an illness, pregnancy or accidental injury…”. The Plan goes on to say the service must meet all of the following conditions:

  • It is accepted by the health care profession in the U.S. as the most appropriate level of care.
  • It is the safest and most effective level of care for the condition being treated.
  • It is appropriate and required for the diagnosis or treatmentof the accidental injury, illness or pregnancy.
  • There is not a less intensive or more appropriate place of service, diagnostic or treatment alternative that could have been used in lieu of the place of service or supply given.
  • The treatment is provided in a clinically controlled research setting.
  • It is not an Experimental or Investigative Treatment, Drug, or Device.

In third amended complaint, Plaintiffs bring both an ERISA recovery action and a Parity Act claim.  Defendants move to dismiss the Parity Act claim pursuant to a 12(b)(6) motion.

  • Holding. The Court re-stated the four requirements to assert a Parity Act claim:
    • [His or Her] insurance plan is subject to the Parity Act;
    • The plan provides benefits for both mental health/substance abuse and medical/surgical treatments;
    • There are differing treatment limitations on benefits for mental health care as compared to medical/surgical care; and
    • Such limitations on mental health care are more restrictive.

As Defendant’s challenge Plaintiffs’ “as applied” parity violation, the judge writes:

The court also notes that while the Third Amended Complaint is sufficient to survive Defendants’ motion to dismiss, there is also some ambiguity in Plaintiffs’ factual allegations. The fault for that ambiguity, however, does not necessarily lie with Plaintiffs because the specifics as to how UBH interpreted and applied the Plan to A.K.’s situation is information held within UBH’s exclusive control. And, as such, “Plaintiffs cannot be expected to plead facts that are in the possession of Defendants.”

The Court dismisses non-employee parent from the case and denies Defendant’s motion to dismiss parity act claim or employee parent’s individual ERISA claim.