• Filing. Filed in U.S. District Court for the District of Utah on February 7, 2020 (Case no. 2:18-cv-383-JNP-PMW).
  • Backgroun This case is very similar to the David P case above and is decided by the same Judge, Jill N. Parrish. Plaintiff’s son has struggled for some time with addiction issues and has been diagnosed with a number of mental health issues including HDHD, anxiety, and depression including threats of suicide.  He has been admitted to a licensed/accredited outdoor behavioral health program (Open Sky), licensed residential treatment center (Crossroads) and young adult treatment facility that provides a structured environment designed to help ease the transition from residential treatment and wilderness programs to independent living (AIM House).  Most of his care was denied by Oxford for a number of different reasons including lack of preauthorization, lack of medical necessity and experimental treatment exclusions – among other reasons.  The denial of care was upheld during all appeals.  Plaintiff brings a breach of fiduciary ERISA action and a Parity Act violation.   Plaintiff asserts that Oxford failed to engage during the appeals process meaningfully and coherently, did not act in the son’s interest, and failed to cover medically necessary treatment based on the terms of the plan.

Defendant seeks to dismiss the second amended complaint (SAC) under Rule 12(b)(6) based on the following three arguments:

  • Standing — Plaintiff lacks statutory and constitutional standing to bring his individual claims.
  • Pending Class Action — Plaintiff’s son is a member of a pending class action that Defendant believes is premised on the same grounds as this lawsuit (Wit).
  • Parity Claim — Parity Act claim is inadequately pled and should be dismissed with prejudice.
  • Holding. For the following reasons, the Court rejects all of Defendant’s arguments and denies its Motion to Dismiss.
  • Standing – Yes. The Court ruled that the Plaintiff has standing to sue in part because he incurred over $128,000 in medical expenses for his son’s care at Crossroads, Open Sky, and Aim House.  Plaintiff asserts that this was due to Defendant’s alleged wrongful denial of benefits.  Therefore, this “allegation satisfies the first two elements of constitutional standing—that Plaintiffs were injured and that Defendants caused /the ”
  • Pending Class Action – Not Applicable. Among other reasons, the Court denies Defendants attempt to include Plaintiff in the Wit class for the following reasons: 1) Oxford and UBH are different legal entities; 2) lack of substantial overlap for purposes of the first-to-file doctrine; 3) and the Wit case did not include a Parity Act claim.
  • Parity Claim Allowed. The Court ruled that the Parity Act claim is adequately pled both on its face and as applied.  The Court agreed that Plaintiff has met the initial pleading requirement that:
  • “Defendant (could have) committed ‘facial’ violations of the Parity Act because the Plan’s categorical exclusion of wilderness therapy and transitional living centers imposes separate or more restrictive treatment limitations on mental health/substance abuse services as compared to medical/surgical services.”
  • “Defendant (could have) committed ‘as-applied, Parity Act violations because it applied its medical necessity criteria and experimental/investigational care exclusion policy on mental health/substance abuse care more stringently that it would apply the same facially neutral limitations to analogous medical/surgical care.