2019 and Earlier Parity Case Highlights

Violation Category: Psychiatric treatment in residential treatment center for major depressive disorder

Short Description: Plaintiff seeks to end Microsoft’s discriminatory practice of excluding all coverage from the Plan for psychiatric treatment in residential treatment centers (except for treatment of eating disorders). S.S. was diagnosed with major depressive disorder and required treatment from a residential treatment center. S.S. had to pay for treatment received from the residential treatment center out of pocket. S.S. completed the internal appeal process and exhausted her administrative remedies.

Appeal/Disposition: The Court granted Defendants’ Motion to Dismiss. Plaintiff appealed but later voluntarily dismissed the appeal.

Violation Category: Long-term residential treatment services for depression

Short Description: Plaintiffs filed suit against Sinclair Services Company and Sinclair Services Company Point of Service Basic Plan after Sinclair’s Plan Administrator denied the family’s claim for benefits relating to long-term residential treatment services rendered to the family’s minor daughter, N.F., for depression. Plaintiffs argued it was due benefits under the Plan for two reasons: first, the Administrator abused its discretion when it denied the F. Family’s claim for benefits incurred before January 1, 2013, based on an unreasonable interpretation of the Plan’s terms and second, the family was entitled to benefits incurred on or after January 1, 2013, because the 2013 amendment to the Plus Plan excluded coverage for residential treatment services violated the Party Act.

Appeal/Disposition: The F. Family and the Plan Administrator cross-moved for summary judgment on the F. Family’s claim for benefits. Both Motions were granted in part and denied in part. The Court remanded the matter to the Administrator.

Violation Category: Treatment limitations on ABA therapies for ASD and treatment limitations for NDT therapies for pervasive developmental disorder-not otherwise specified and developmental delays

Short Description: Plaintiff alleged that Premera adopted a uniform policy excluding coverage for neurodevelopmental therapy (NDT) to treat DSM conditions for individuals over the age of six and imposed visit limits on such therapies when covered under its “rehabilitation” benefit. Plaintiff further alleged that he was denied coverage for speech and occupational therapy necessary to treat his DSM condition of pervasive developmental disorder-not otherwise specified and developmental delays after reaching visit limits under his rehabilitation benefit. Plaintiff contended that to the extent that Premera provided any coverage of NDT or ABA therapies, it generally imposed treatment limitations that were not at parity with coverage for medical and surgical services.

Appeal/Disposition: The Court granted Plaintiff’s Motion for Preliminary Approval of the class settlement.

Violation Category: Outpatient, in-network mental health office visits for an unspecified mental health disorder

Short Description: Plaintiff alleged that the limits placed on mental health office visits by her health care plan violated the MHPAEA and that Defendant breached its fiduciary duty by enforcing it. Plaintiff sought to certify a class of other individuals enrolled in large, self-funded plans administered by UHC and requested, on behalf of the class: an Order declaring that visit limits on mental health services are void and unenforceable; UHC be permanently enjoined from including similar plan provisions in the future or from applying such terms if they appeared in other plans; and an Order requiring UHC to provide “accurate information concerning mental health coverage in all class members’ plans.”

Appeal/Disposition: Defendant’s Motion for Judgment on the Pleadings or, in the alternative, to Compel Joinder of a Necessary Party was denied. The case later settled.

Violation Category: Applied Behavior Analysis therapy for Autism Spectrum Disorder

Short Description: Plaintiff argued that T-Mobile adopted a uniform policy excluding any coverage for ABA therapy to treat ASD, including any coverage that may be medically necessary. Plaintiff alleged that he was denied coverage for ABA therapy to treat his ASD, and when Plaintiff appealed, T-Mobile denied his appeals with the justification that ABA therapy was excluded from the Plan.

Appeal/Disposition: Plaintiff’s unopposed Motion to Certify the Class was granted, but the Court denied Plaintiff’s unopposed Motion for Preliminary Approval of the Settlement Agreement.

Violation Category: Inpatient detoxification for unspecified disorder

Short Description: Plaintiff’s son received inpatient detoxification treatment at the behest of his physicians. Plaintiff argued a systematic violation of MHPAEA and requested class certification. The Defendant no longer provides any claims administration and does not administer any commercial health plans, thus rendering moot the Plaintiff’s claims. Additionally, Defendant argues that the individualized monetary damages are the only remedy that Plaintiffs seek and that this is improper for the Court to address in a class certification.

Appeal/Disposition: Plaintiff’s motion for class certification is denied, Defendant’s motion to deny class certification is granted.

Violation Category: Out-of-network inpatient treatment for an unspecified mental health disorder.

Short Description: Plaintiff’s father sought prior authorization for Plaintiff to be treated at an out-of-network treatment center. Without prior authorization, Plaintiff would be required to pay all costs out of pocket. Plaintiff sought prior authorization for more than 2 weeks. Defendant never approved, nor denied the claim. Plaintiff filed suit and argues breach of the covenant of good faith and fair dealing, breach of contract, fraudulent concealment, anticipatory breach of contract, violations of the Affordable Care Act (ACA) and MHPAEA

Appeal/Disposition: Defendant’s motion to strike is granted. Defendant’s motion for judgment on the pleadings is denied as to the breach claim and granted as to all others. Plaintiff’s motion to amend their complaint is granted as to the breach claim and denied as to all others. Plaintiff’s claims for fraudulent concealment, anticipatory breach of contract, and failure to comply with the ACA and MHPAEA are dismissed with prejudice.

Violation Category: Plaintiff’s son’s Applied Behavior Analysis (ABA) treatment for his autism spectrum disorder (ASD) was denied.

Short Description: The trial court had stated that the Parity Act only requires coverage for services that are medically necessary, and thus that the question of medical necessity must be asked for each individual in the class. However, the Court states that this is too narrow of a reading, and that the Plaintiff could prove a statutory violation by showing that Defendant categorically denies coverage for coverage that may, in some cases, be medically necessary without considering the question of medical necessity. The Court finds that the Plaintiff’s complaint sufficiently alleges that Defendant has a policy of categorically denying coverage without determining medical necessity.

Appeal/Disposition: Court reversed the order sustaining the demurrer and remanded to the trial court.

Violation Category: Plaintiff was prescribed 40 hours per week of applied behavioral analysis treatment (ABA) for his autism spectrum disorder (ASD). This coverage was reduced to 20 hours.

Short Description: Plaintiff’s parents bring the action on behalf of W.P. W.P, is 13 and suffers from severe autism. He has limited verbal skills, is unable to navigate stairs and exhibits repetitive behaviors. W.P.’s provider prescribed 40 hours per week of ABA therapy. Defendant denied this coverage as the plan only covered 20 hours per week for individuals over age 7. Plaintiffs filed the putative class action asserting the Defendant’s practice of limiting the hours of ABA therapy violates ERISA in that it fails to comply with Indiana’s Autism Mandate and other federal laws. Plaintiffs seek damages, an injunction from the Court and argue that Defendant breached its fiduciary duty to Plaintiffs.

Appeal/Disposition: This case settled. If the proposed Settlement Order is approved by the Court, Anthem will pay nearly $1.63 million for autism coverage claims and will eliminate its guidelines on autism treatment based on an individual’s age. Upon Court approval, Anthem will also issue a statement to its employees regarding the use of age-related considerations and will require employees who review treatment plans to participate in periodic external continuing education related to autism and ABA therapy.

Violation Category: Reimbursement for various treatments

Short Description: :A polyglot group of unrelated plaintiffs who ether 1) applied to their employer-sponsored health plan for reimbursement of the cost of mental health care or substance abuse treatment, or 2) provided mental health care for which their patients were not fully reimbursed by their employer-sponsored health plans. In each instance, Defendants had something to do with the denial of benefits sought. Plaintiffs seek money damages and an injunction requiring United to treat mental health or substance abuse benefits no less favorably than it treats medical or surgical benefits when it assesses whether claims are reimbursable under various employer-sponsored health plans.

Appeal/Disposition: United moved to dismiss all claims asserted, arguing that every plaintiff failed to state a claim against it and that the NYSPA lacks standing to pursue any claim. Plaintiffs cross-moved for a preliminary injunction, seeking to enjoin United’s practices that allegedly violate mental health parity laws. As to all claims, the motion to dismiss was granted.