Patrick S. v. United Behavioral Health. (U.S. Dist. CT. for the District of Utah, case no. 2:20-CV-283-TS, Jan 29, 2021). In this case, the Defendant denied reimbursement to Plaintiff after an initial period of stay at both a licensed outdoor wilderness and residential treatment center (RTC). The denial at the outdoor wilderness was made because United determined that these programs are “experimental” and “unproven”. The denial of care was upheld during the appeals process in part because the Plaintiff was not at risk of harm to himself or others and was medically stable according to the plan. Similarly, the Plaintiff was not reimbursed at the RTC facility based on the level of care guidelines. A lower level of care (i.e., PHP) was approved by the plan. The denial of care at the RTC was upheld during the appeals process. Plaintiff filed several ERISA actions, including an “as-applied” claim under the Parity Act. Defendants filed a motion to dismiss the Parity Act claim.
Judge Ted Stewart denied Defendants’ motion to dismiss the Parity Act claim. He noted: “there is no clear law on how to state a claim for a Parity Act violation, so district courts have continued to apply their own pleading standards. Notably, courts in this jurisdiction favor permitting Parity Act claims to proceed to discovery to obtain evidence regarding a properly pleaded coverage disparity.”
The Court referenced the three elements of asserting a parity action covering: 1) identify the specific MH/SU treatment limitation; 2) identify the analogous med/surg services at issue; and 3) plausibly allege a disparity in the limitation criteria applicable to the analogous med/surg services when compared to the similar MH/SUD services. The Court reviewed each element and ruled that the Plaintiff had met the pleading burden at this stage. Judge Stewart noted that the Defendants are asking the Court to look into the merits of the claim but he concludes that is not appropriate at this stage when addressing a motion to dismiss.