2019 and Earlier Parity Case Highlights

Violation Category: In-Patient Wilderness Treatment Program

Short Description: Plaintiff’s son struggled with mental health issues such as early childhood trauma, complex post-traumatic stress disorder, attention deficit hyperactivity disorder, depression, low self-esteem and drug use. In February 2015, his therapist concluded that he was no longer treatable in an out-patient setting, and recommended intensive, in-patient treatment. He was transmitted to Second Nature Therapeutic Wilderness Program, a mental health service provider based in Utah. Plaintiff sought coverage under the NextEra health and welfare benefits plan, which was denied.

Appeal/Disposition: Plaintiff did not exhaust all available administrative remedies before filing suit and did not put forth any “clear and positive showing of  futility” and otherwise persuade the Court that he should be excused from the administrative exhaustion requirement. Plaintiff’s case is dismissed with prejudice. The time for Plaintiff to exhaust his administrative remedies expired, due to no fault of Cigna. Therefore, Plaintiff was not able to refile his ERISA claims against Cigna based on the denial of coverage referenced in the Second Amended Complaint.

Violation Category: Residential Treatment

Short Description: Appellant appealed the district court’s judgment in favor of the United Healthcare Insurance Company, affirming denial of benefits. Appellant contends that United’s denial was not supported by the record and was contrary to the guidelines used both by United and treating professionals in the mental health field.

Appeal/Disposition: The district court did not err when determining whether Appellant’s stay at Sierra Tucson was medically necessary as covered by the Plan. Appellant failed to show by a preponderance of the evidence that the treatment she received ay Sierra Tucson was medically necessary or in compliance with United’s applicable guidelines.

Violation Category: ABA therapy

Short Description: P.S., a six-year-old girl with autism, sought coverage for ABA therapy. Her treatment was denied.

Appeal/Disposition: Defendants’ Motion for Partial Summary Judgment on Plaintiffs’ second claim for relief (disparate treatment), third claim for relief (disparate impact), and forth claim for relief (violation of public policy) based on the one-year statute of limitations was denied. Defendants’ Motion for Partial Summary Judgment on Plaintiffs’ second claim for relief (disparate treatment), third claim for relief (disparate impact), and forth claim for relief (violation of public policy) based on failure to establish the elements of “associational disability discrimination” was denied. Defendants’ Motion for Partial Summary Judgment on Plaintiffs’ claim for injunctive relief based on the claim being “moot” was denied.

Violation Category: Residential Treatment

Short Description: Plaintiffs sought to recover benefits for Kirstyn’s residential treatment.

Appeal/Disposition: The Court agreed with Aetna that because New Haven does not meet the Plan’s definition of a Residential Treatment Facility, and because Plaintiff failed to obtain pre-certification as required, Plaintiffs’ claim for coverage at New Haven was properly denied. Defendants’ Motion for Summary Judgment was granted.

Violation Category: Transcranial Magnetic Stimulation (“TMS”) for treatment of depression

Short Description: Plaintiff filed suit for the denial of TMS for the treatment of depression.

Appeal/Disposition: This case settled.

Violation Category: Non-restorative speech therapy treatment (neurodevelopmental therapy)

Short Description: In 2006, Defendant Group Health diagnosed Z.D. with two DSM-IV-TR mental health conditions: a “moderate-severe receptive language disorder” and “other specific developmental learning disabilities.” At the time of her diagnoses, Z.D. began receiving covered non-restorative speech therapy treatment for her conditions. Circumstances changed, however, shortly before Z.D.’s seventh birthday. Plaintiff was told that, per the Plan, non-restorative speech therapy treatments were not covered for individuals over the age of six and thus her treatments would no longer be covered once she turned seven.

Appeal/Disposition: Defendants were ordered to cease denying coverage for medically necessary neurodevelopmental therapy to treat insureds with DSM-IV-TR mental health conditions simply because the insured was over six years old. Defendants were also ordered to cease their application of any treatment limitations that are not generally “imposed on coverage for medical and surgical services.”

Violation Category: Applied Behavior Analysis (ABA) therapy for Autism Spectrum Disorder (ASD)

Short Description: Plaintiffs sought to end Boeing’s allegedly discriminatory practice of excluding all coverage under the Plan for treatment of ABA therapy to treat ASD.

Appeal/Disposition: This case settled. The agreed-upon removal of the exclusion from coverage for the treatment from the terms of the plan, the absence of caps or visit limits, and a $900,000 fund established to pay for retrospective claims, attorney fees, and costs were found to be fair, reasonable, and adequate.

Violation Category: Applied Behavioral Analysis (ABA) therapy for children with autism

Short Description: D.M. alleged that GHC wrongfully denied health insurance coverage to D.M. for ABA therapy. D.M. alleged that the denial of coverage breached the contract for insurance and failed to comply with the Washington MHPA, in violation of the Consumer Protection Act (CPA). The parties stipulated to the filing of early summary judgment motions on the underlying substantive legal issues presented by D.M.’s Complaint. GHC sought the dismissal of all claims and, in turn, D.M. sought partial summary judgment and requested that the Court rule that GHC was in violation of the MHPA.

Appeal/Disposition: The Court found that there were genuine issues of material fact requiring the Court to deny both parties’ motions for summary judgment.

Violation Category: Applied Behavioral Analysis (ABA) therapy for autism

Short Description: Plaintiffs sought partial summary judgment in the form of an injunction requiring Washington Healthcare Authority (HCA) to cover Applied Behavioral Analysis (ABA) for children with autism for whom the service was medically necessary. Plaintiffs aruged that ABA therapy can enable children with autism to attend school, even in mainstream classrooms, or avoid institutionalization.

Appeal/Disposition: The Court concluded that Plaintiffs were entitled to a declaration that specific exclusions contained in health benefit plans administered by the Defendants that excluded coverage of ABA therapy, even when medically necessary and performed by licensed health providers, did not comply with Washington’s Mental Health Parity Act. The Court further declared that under the Mental Health Parity Act Defendants were required to cover medically necessary ABA therapy, as determined on an individualized basis, when provided by licensed providers.

Violation Category: Neurodevelopmental therapies for autism

Short Description: Plaintiff alleged that the exclusion of  “services, therapy and supplies related to the treatment of … developmental delay or neurodevelopmental disabilities” violated Washington public policy and the Parity Act.

Appeal/Disposition: Plaintiff’s Motion for Partial Summary Judgment and Preliminary Injunction was granted and Defendant’s Motion to Dismiss was denied.