2019 and Earlier Parity Case Highlights

Violation Category: The Plaintiff provided inpatient psychiatric care under Idaho’s Medicaid program. Defendant denied at least some portion of Medicaid reimbursement in all three cases. The Plaintiff appealed the decision to deny reimbursement and filed petitions for judicial review. The district court reversed the decisions of the Defendant and ordered reimbursement in full in all three cases.

Short Description: Four issues are argued on appeal: 1) whether Plaintiff has standing to assert the due process rights of its patients; 2) whether Idaho documentation requirements conflict with federal certification requirements; 3) whether the hearing officer’s preliminary orders were supported by substantial evidence; and 4) whether Defendant is entitled to an award of attorneys fees and costs.

Appeal/Disposition: On appeal, the court affirmed that the care was properly denied because the record lacked documentation sufficient to demonstrate the medical necessity criteria. This seems to indicate that the lack of supporting evidence in a medical record, rather than the opinion of the medical professionals treating J.M., was the cause of the denial of care

Violation Category: Plaintiffs A.F. and A.P. are dependent beneficiaries diagnosed with Autism Spectrum Disorder and prescribed ABA therapy. Defendant denied coverage of the therapy because it is a “service related to developmental disabilities, developmental delays or learning disabilities” (the Developmental Disability Exclusion). Defendant otherwise covers services related to Autism. Plaintiffs bring a motion for summary judgment based on Defendant’s violation of the Oregon Mental Health Parity Act, the Oregon Mandatory Coverage for Minors with Pervasive Developmental Disorders Act and the Federal Parity law.

Short Description: In looking at the Oregon Mental Health Parity Act, the Court found that the text and the legislative intent both support the Plaintiff’s argument that the Exclusion is unlawful. The Exclusion does not provide equal coverage to medical/surgical benefits and is inconsistent with the spirit of the statute. Finally, the Court examined whether the Exclusion is unlawful under MHPAEA. The Defendant argues that MHPAEA does not require coverage of any specific treatment but only requires that if a certain treatment or service is covered that it must be covered equally for MH/SU and medical/surgical claims. Plaintiffs argue that the Exclusion violates MHPAEA in that it is a treatment limitation applicable only to mental health disorders. The Court finds Defendants arguments unpersuasive and that the Exclusion is overtly applicable only to mental health conditions, thus violating MHPAEA.

Appeal/Disposition: The Plaintiff’s motion for summary judgment is granted and the Defendant’s motion for summary judgment is denied.

Violation Category: Plaintiff B.S. is 9-years-old and suffers from autism. His request for coverage of speech and language therapy was denied by Defendant because they do not cover the treatment for individuals above age 6. Before the Court is the Plaintiff’s motion for preliminary injunction and class certification.

Short Description: Plaintiffs allege Defendants have failed to comply with both the Washington state Parity Act and MHPAEA. Specifically, Plaintiffs bring three claims: 1) a breach of fiduciary duties under ERISA § 404(a)(1); 2) recovery of benefits, clarification of rights under the term of the plans, and clarification of rights to future benefits under the plan pursuant to ERISA § 502(a)(1)(B); and 3) to enjoin acts and practices in violation of the terms of the plans, to obtain other equitable relief, and to enforce the terms of the plan pursuant to ERISA § 502(a)(3). Defendants argue that plaintiffs do not have standing to bring an ERISA claim. The Court does not agree with this line of reasoning, stating that B.S. suffered an injury in fact when Defendant denied coverage of the treatment, that the denial of coverage is casually connected to Defendant’s practice of excluding coverage based on the insured’s age, and that the injury will be redressed by injunctive relief. In determining whether to grant the preliminary injunction, the Court considers whether the Plaintiffs are likely to succeed on the merits, whether there is a risk of irreparable harm, and balances equities with the public interest. The Court finds that the Plaintiffs are likely to succeed on the merits because the age-based restriction is an exclusion of coverage and is likely invalid. The Court also certifies the class of plaintiffs.

Appeal/Disposition: The Court grants Plaintiff’s motion for preliminary injunction and class certification.

Violation Category: Coverage of certain intensive behavioral therapies used to treat plaintiff’s son’s autism spectrum disorder were denied as they were excluded under the terms of the plan.

Short Description: Plaintiff’s seven-year old son suffers from autism. He was identified as developmentally delayed by his first birthday and began receiving physical therapy to address his delayed walking, speech, and motor skills. By age two, he was exhibiting multiple violent tantrums daily, aggressive behavior toward his peers and school staff, and severe social limitations. He was referred for intensive behavioral therapy for up to 40 hours per week. The therapy proved to be greatly beneficial and reduced his violent tantrums and behavior, boosted his IQ, and allowed him to be integrated 100% of the time with his non-disabled peers at school. The provider specifically excluded coverage of intensive behavioral therapy treatment programs for the treatment of autism spectrum disorders. A categorical exclusion of this type, particularly where no similar exclusion exists denying medical/surgical benefits, violates the spirit of MHPAEA.

Appeal/Disposition: The motion to dismiss was granted in part and denied in part.

Violation Category: Plaintiffs J.T. and S.A. seek to bring a class action suit against Defendant insurer. Plaintiff J.T. is a 10-year-old who is diagnosed with Articulation Disorder and Receptive/Expressive Language Disorder. He received neurodevelopmental speech therapy as treatment but Defendant denied this claim under the plan’s categorical exclusion of neurodevelopmental therapy to individuals over age six. Plaintiff S.A. was born with Down Syndrome. Her mother asked Defendant if it would cover speech therapy for her daughter (aged 16 at the time). Defendant never responded. Plaintiffs allege a violation of the Washington Mental Health Parity Act. Plaintiff S.A. brings a motion for summary judgment and a motion for class certification. Defendant brings a motion to dismiss.

Short Description: Plaintiffs J.T. and S.A. allege Defendants violated the Washington Mental Health Parity Act when they denied Plaintiffs neurodevelopmental treatment based on an exclusion in the plan to only cover the treatment when provided to individuals age 6 and under. Defendants bring a motion to dismiss, arguing that Plaintiffs do not have subject matter jurisdiction. The Court finds that J.T. does have standing to bring the claims. Defendants had argued that J.T. did not have standing because the plan was not delivered on or after July 1, 2010 after the Parity Act had been fully implemented. Defendants also argue that the exclusion is an exclusion from coverage rather than a treatment limitation and thus not a violation of the Parity Act. The Court disagrees. Plaintiff’s motion to certify the class was denied by the Court. Plaintiff S.A. did satisfy the numerosity requirement, but failed to demonstrate the typicality requirement because she was diagnosed with Down Syndrome, and thus not a typical class member. The Court also questioned S.A.’s suitability as a class representative. Finally, the Court considered S.A.’s motion for summary judgment. S.A. argued that summary judgment was proper because “it is undisputed that [her] recommended speech therapy is designed to treat her DSM-IV-TR mental health conditions.” However, Defendants argued that the diagnosis was not correct. Thus the Court found that summary judgment was improper.

Appeal/Disposition: The Plaintiff’s motion for class certification is denied. Plaintiff’s motion for summary judgment is denied. Defendant’s motion to dismiss is denied.

Violation Category: Plaintiff’s minor son was diagnosed with autism at the age of one year and nine months. Approximately six months later, Plaintiff began ABA treatment for her son. These claims were denied and Plaintiff exhausted the internal administrative appeals process and requested an external independent review. Defendant argues that the treatment is not medically necessary or, in the alternative, that the treatment falls within one of the following exclusions: 1) experimental or investigational procedures, 2) educational services, or 3) academic and social skills training.

Short Description: In examining the case, the Court states that to be entitled for reimbursement, the treatment must be medically necessary, a covered benefit under the Plan, and provided by an eligible provider. The Plaintiff successfully proved that the treatment was medically necessary by submitting three letters written by J.M.’s pediatrician to Defendant. In determining whether the treatment was a covered benefit, the Court considers whether it falls under one of the three classifications: 1) experimental or investigational, 2) educational services, or 3) academic and social skills training. The Court finds the treatment does not fall under an exclusion. The Court then moves to consider whether J.M.’s treatment is provided by an eligible provider and finds that the provider (Hoyt) is not an eligible provider.

Appeal/Disposition: Plaintiff’s motion for summary judgment is denied. Defendant’s motion for summary judgment is granted.

Violation Category: There are two named Plaintiffs – six-year-old O.S.T. and two-year-old L.H. O.S.T. was diagnosed with autism and receives speech, physical and occupational therapy and continued to receive neurodevelopmental therapies. L.H. was diagnosed with expressive language disorder, myotubular myopathy, profound hypotonia, and severe hydrocephalus. L.H. also receives speech, occupational, and physical therapy. Both Plaintiffs are, or were, insured by Defendant. Both Plaintiffs’ policies contained blanket exclusions for neurodevelopmental therapy.

Short Description: The Defendants argued that the Washington Mental Health Parity Act and the WA Neurodevelopmental Therapies Mandate conflict. In support of its argument that the two statutes do conflict, Defendants argue that the neurodevelopmental therapies are an exception to the Parity Act based on the statutory maxim expression unius est exclusion alterius. In its application, the Defendants argue that the NDT mandate has positive and negative requirements and that ultimately, the NDT statute conflicts with the Parity Act. The Court does not find this argument persuasive because the statutory language is not ambiguous. The Defendants also argue that where the legislature adopts a general statute after a specific statute, the original specific statute is an exception to the general statute unless repealed. However, again, the statutes do not conflict. The Court also states that it disfavors repeals by implication and that in this case, the two statutes can stand side-by-side and both be held valid.

Appeal/Disposition: Ultimately, the Court finds that summary judgment was proper and that the blanket exclusion violates the WA Parity Act.

Violation Category: Plan categorically denied coverage for behavioral and speech therapies for children suffering from autism

Short Description: Plaintiff’s son displayed a lack of speech and a lack of affection and was referred to speech and occupational therapists to determine whether his symptoms indicated he was autistic. The payer repeatedly cancelled and rescheduled the assessment appointment over a period of four and on-half months. He was finally diagnosed with autism and providers recommended two hours of occupational therapy per month but denied coverage for any other therapies to treat his autism. Plaintiff appealed the Defendant’s decision with the Department of Managed Health Care (DMHC) and requested an independent medical review. The independent reviewer overturned the decision to deny coverage; this decision was adopted by the DMHC.  The Court considers whether the CA Parity Act allows Defendant to exclude the therapy on the grounds that it is a non-health care service, an academic or educational intervention, or custodial care. The Court states that this is a question of statutory interpretation. 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 brings this individual action against Defendant insurer. Plaintiff is a 25-year-old resident of New York and was a covered dependent under her father’s employer-sponsored group health plan. Plaintiff suffers from an eating disorder and was admitted to a treatment center for treatment; Defendant denied Plaintiff’s preauthorization for this service as it was deemed not medically necessary. Plaintiff appealed and was denied. After completing residential treatment, Plaintiff sought authorization to continue treatment in an Intensive Day Program. This was also denied as not medically necessary.

Short Description: The motion before the Court for limited discovery is based upon Plaintiff’s argument that the administrative record lacks any documentation about the potential conflict of interest between UBH and Oxford relating to the claims process. Plaintiff argues that the Court should permit to her to conduct discovery to determine if the insurance company’s experts and doctors were independent. The Court agrees with Plaintiff’s argument and grants Plaintiff’s Motion.

Appeal/Disposition: The Court grants Plaintiff’s Motion for Limited Discovery but denies to grant the request for a deposition of Defendant’s designated representative.

Violation Category: The Plaintiff, a covered dependent, brings suit against the Defendant insurer for damages when the Defendant denied claims for her inpatient and outpatient therapy for an eating disorder. Plaintiff alleges violations of the New York and Missouri parity laws, claiming that the plan did not provide mental health coverage that is comparable to health benefits under the plan.

Short Description: Defendant brings this Motion to Dismiss arguing that the Plaintiff did not provide any factual basis to support her claims. Defendant argues that her claims were denied because they were not medically necessary. The Court agrees with Defendant’s argument in that Plaintiff did not assert any facts that show a violation of state parity laws.

Appeal/Disposition: The Court grants Defendant’s Motion to Dismiss Count III.