- Filing. Published in U.S. District Court for the District of Utah on April 7, 2020 (Case no. 2:19-cv-00199.
- Backgroun Case involves a denial of care for plan beneficiary with autism. Plan was self-funded though Microsoft and Premera served as the TPA. Denial was based on lack of “medical necessity.” Denials were upheld during the internal and external appeal reviews. Legal action involves both an improper denial of benefits under ERISA and a parity violation. Plaintiffs assert that TPA used “incorrectly conflated acute and subacute levels of care” in part because the TPA failed to impose similar requirements “such as acute symptomology on analogous intermediate levels of care such as skilled nursing facilities.” Defendants filed a 12(b)(6) motion to dismiss.
- Holding. Motion to dismiss is denied. Judge Robert J. Shelby notes “Plaintiffs have sufficiently identified the imposition of acute medical necessity criteria as the relevant nonquantitative treatment limitation.” He also notes that Plaintiff’s Parity Act claims is not a mere repackaging of their denial of benefits in part because the “denial of benefits claim and Parity Act claim, while both based on similar facts, may well represent two different injuries.”
As part of his published opinion, Judge Shelby identifies the elements of “a facial” and “as applied” parity violation. In addition to allowing the Plaintiff’s claims to move forward, the court also refused to rule on the Defendant’s Opposition to allow the Plaintiff’s Motion for Discovery. The court is deferring the resolution of this issues with the Magistrate Judge.