2019 and Earlier Parity Case Highlights

Violation Category: Residential Treatment/Wilderness Therapy

Short Description: Plaintiff alleges that BCBSKC improperly denied reimbursement for inpatient mental health treatment that R.H. received at the Elements Wilderness Programs and Boulder Creek Academy from January 20, 2016 to March 17, 2017.

Appeal/Disposition: Defendant’s Motion for Summary Judgment was granted, and Plaintiff’s Motion for Summary Judgment was denied.

Violation Category: Residential Treatment

Short Description: Mike and Maddie filed their single-count Complaint seeking recovery of benefits under 29 U.S.C § 1132(a)(1)(B). Under Count One, Plaintiffs also alleged that Anthem breached its fiduciary duties under 29 U.S.C. § 1104 and § 1133 by failing to act solely in the interest of the Plan participants and beneficiaries when it denied Maddie’s benefits and by failing to provide a full and fair review as required under the Plan and by ERISA.

Appeal/Disposition: Plaintiffs sought judgment in the amount of $200,000.00, plus prejudgment interest pursuant to Utah Code Ann. § 15-1-1, and attorney fees and costs incurred under 29 U.S.C. § 1132(g). The court held oral argument on the motions and, on the basis of that hearing, the parties’ briefs, and a review of the relevant law, the court granted in part and denied in part Anthem’s Motion for Summary Judgment and granted in part and denied in part Plaintiffs’ Motion for Summary Judgment.

Violation Category: Residential Treatment

Short Description: The parties filed cross-Motions for Summary Judgment. Plaintiffs sought review of Premera’s denial of benefits under the plan. Specifically, Premera declined to cover a portion of Lillian R.’s stay at a residential treatment center as not medically necessary. Plaintiffs repeatedly appealed Premera’s decision, but at each level of review, the denial was affirmed. Plaintiffs therefore filed suit in an effort to recover the denied benefits.

Appeal/Disposition: Based on the Court’s review of the record and its consideration of the parties’ arguments, the Court concluded that Lillian R.’s residential treatment at issue was medically necessary and therefore covered under the plan. Judgment was entered in favor of the Plaintiffs.

Violation Category: Wilderness Therapy Programs and Residential Treatment

Short Description: Plaintiffs initiated this lawsuit, asserting claims under ERISA and the Federal Parity Act.

Appeal/Disposition: Defendant’s Motion to Dismiss was granted without prejudice.

Violation Category: Residential Treatment

Short Description: Plaintiff, on behalf of himself and other similarly situated, alleged that Kaiser’s pattern and practice of treatment for eating disorders violated ERISA and the California and Federal Health Parity Acts.

Appeal/Disposition: Plaintiff’s medical records clearly indicated that although his treating therapist determined that he required a higher level of care, he was not amenable to a referral within the Kaiser medical system and instead elected to pursue a residential treatment program that was out of network and required out-of-pocket payment from his parents. Because Plaintiff’s therapist was willing to make a referral and the Plan did provide for residential treatment of eating disorders, Plaintiff failed to raise disputed issues of fact regarding his claim for breach of fiduciary duty. As such, Defendant’s Motion for Summary Judgment was granted.

Violation Category: Residential Treatment

Short Description: Plaintiff filed suit against Companion Benefit Alternatives, Inc. (CBA) for plan enforcement under 29 U.S.C. § 1132(a)(1)(B) and violation of the Parity Act. Defendant filed a Motion to Dismiss.

Appeal/Disposition: Defendant’s Motion to Dismiss the Amended Complaint was granted, and the case was dismissed without prejudice.

Violation Category: Partial Hospitalization for Eating Disorder Treatment

Short Description: Ariana M. sued Humana Health Plan of Texas, Inc. alleging that Humana had wrongfully denied benefits for 106 days of partial hospitalization to treat an eating disorder. Humana had paid for 49 days of partial hospitalization before determining that Ariana M. did not meet the criteria for continued coverage at that level. Instead, she was covered for the next level of care (Intensive outpatient). The U.S. District Court for the Southern District of Texas granted summary judgment for Humana, holding that it did not abuse its discretion in denying the benefits. Ariana M. appealed. On appeal, the Fifth Circuit acknowledged that its standard of review for ERISA cases was at odds with that of most circuits and changed the law. The Fifth Circuit held that district courts are to review <em>de novo </em>a plan administrator’s decision to deny coverage under an ERISA plan. The Fifth Circuit vacated the order granting summary judgment and remanded for the District Court to apply the <em>de novo.</em>

Appeal/Disposition: Humana’s Motion for Summary Judgment and Motion to Strike were granted and Ariana M.’s Cross-Motion for Summary Judgment and Motion for Attorneys’ Fees were denied.

Violation Category: Residential and Intensive Outpatient Treatment

Short Description: Plaintiffs contend that Defendants violated legal and fiduciary duties they owed to health insurance plan participants and beneficiaries by improperly restricting the scope of their insurance coverage for residential and intensive outpatient mental health and substance abuse treatment. Plaintiffs further alleged that these restrictions were inconsistent with the terms of the relevant insurance plans and generally accepted professional standards in the mental health and substance abuse disorder treatment community.

Appeal/Disposition: Plaintiffs’ unopposed Motion for Settlement was granted.

Violation Category: Residential Treatment

Short Description: Plaintiff brought this action under ERISA, challenging Defendant’s denial of mental health benefits for residential treatment services provided for his 17-year-old son, C.M.

Appeal/Disposition: Plaintiff’s motion for summary judgment was granted to the extent that the Court found that the Plan’s provision excluding coverage for residential treatment services violated the Parity Act. Defendant’s motion for summary judgment was granted as to the Complaint’s Second Claim of Relief, but was otherwise denied. The Court reserved decision as to the appropriate remedy for Defendant’s statutory violation, pending additional briefing. This case later settled.

Violation Category: In-patient treatment for depression and polysubstance dependence

Short Description: Plaintiffs alleged that BCBS improperly denied mental health benefits for treatment received at two in-patient treatment facilities. Plaintiffs filed a Petition for Damages, Penalties and Attorney’s Fees.

Appeal/Disposition: Plaintiffs’ Petition was dismissed with prejudice at Plaintiffs’ costs.