• Filing. Published in U.S. District Court for the District of Utah on June 18, 2020 (Case no. 2:19-cv-975-DAK).
  • Background. Defendants, a self-funded health plan and CIGNA (the TPA), denied coverage for child’s care at a licensed residential treatment facility (CALO) providing sub-acute MH/SUD inpatient treatment for adolescents.  After several denials and appeals, Defendants funded over a year’s worth of treatment at CALO but the last 4 months of care were denied by the plan.  Plaintiffs filed two legal actions, an ERISA breach of fiduciary duty and a Parity Act violation claim.  Defendants move to dismiss the Plaintiff’s second cause of action.
  • Holding. Judge Dale A. Kimbell ruled CIGNA’s dismissal motion is denied and that the parties should move forward to conduct discovery on the Parity Act violation claim.
  • Analysis. The judge noted that ‘(t)he repeated denial and reversal of benefit decisions caused (the Plaintiff) to question whether Cigna was evaluating (the dependent’s) mental health claims according to the same ‘medically necessary’ criteria that it used to evaluate medical/surgical claims.”  To that end, the Plaintiffs “requested plan documents that would resolve those questions during the prelitigation process, but Cigna did not provide her with those documents.”

In addition, the Court noted:

To the extent that Plaintiffs do not have specific documents to support their allegations, such failure is the result of Cigna ignoring Plaintiffs’ request for documentation during the prelitigation process. Unlike Plaintiffs’ traditional claim for benefits under the Plan, Plaintiffs’ as-applied Parity Act claim rests on facts within Cigna’s control and requires discovery. This court has previously recognized that Parity Act claims will often require discovery to evaluate whether there is a disparity between the plan’s provision of and/or criteria for mental health and substance abuse benefits and medical/surgical benefits. In this case, the parties should proceed to the discovery phase to determine whether Cigna treated mental health benefits differently than medical benefits under the Plan.

The Court also rejected the Defendant’s claim that the ERISA fiduciary breach of care claim is duplicative of the Parity Act violation claim.