1. Case Name: Alexander Carr v. United Healthcare Services, Inc.
2. Type of Treatment Services Denied: Outpatient, in-network mental health office visits for an unspecified mental health disorder
Plaintiff: Daniel Foster Johnson, Breskin, Johnson & Townsend, PLLC; Eleanor Hamburger & Richard E Spoonemore, Sirianni Youtz Spoonemore Hamburger
Defendant: Ruth L Johnson, Ryan McBride, & Barbara J Duffy, Lane Powell, PC
4. Format: Memorandum Opinion and Order on United Healthcare Services, Inc.’s Motion for Judgment on the Pleadings issued by the United States District Court for the Western District of Washington
- ERISA Claim? Yes.
- Class Action/or Individual Action: Class Action
- Defendant: Claims Administrator
- Type of Insurance Plan: Kaiser Aluminum (KA) Fabricated Products LLC Medical Choice Plus Hourly Active Union Plan
- Type of Coverage Denial: The Plan provided the following limitations on outpatient mental health services: up to 20 visits are reimbursed at 100% coverage, the next 20 visits are covered at 50%, and no coverage is provided after 40 visits
6. Legal Pointer: Case settled.
7. Legal Issues and Causes of Action: 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.”
Ruling: Defendant’s Motion for Judgment on the Pleadings or, in the alternative, to Compel Joinder of a Necessary Party was denied.
8. Narrative Case Description: Plaintiff was a beneficiary of the Kaiser Aluminum (KA) Fabricated Products LLC Medical Choice Plus Hourly Active Union Plan (the Plan), an employee welfare benefit plan under ERISA. Plaintiff alleged that United Healthcare Services, Inc. (UHC), as the claims administrator, exercised discretionary authority and control with respect to the administration of the Kaiser Plan. The Plan provided the following limitations on outpatient mental health services: up to 20 visits are reimbursed at 100% coverage, the next 20 visits are covered at 50%, and no coverage is provided after 40 visits. The Complaint alleged that the Plan provided 100% coverage with no treatment limitations for substantially all medical and surgical services covered under the plan, and provided 100% coverage after a co-pay of $15 with no treatment limitations for a small portion of medical and surgical services covered under the plan.
The Court first turned to Plaintiff’s Motions to Strike portions of the Declaration of Jayne Sabo and an accompanying exhibit. The objectionable material concerned an email received from a Department of Labor employee containing her opinion that the Plan did not violate MHPAEA. The Court concluded that the email would not be considered as it was not physically attached to the Complaint nor was it referenced in the Complaint.
The Court then turned to Defendant’s Motion to Dismiss. Defendant made several assertions intended to establish that it had no hand in the design of the Plan, no discretion in administering the Plan, no duty to ignore the Plan if conflicted with federal law, and no idea that the Plan violated the MHPAEA. UHC argued that, in the face of those facts, it had no fiduciary duty. The Court concluded that the factual allegations in Plaintiff’s Complaint were adequate to support her cause of action. The Court opined that Defendant’s argument that it did not have discretionary authority was a factual determination based on the evidence produced regarding the language of the plan and the contractual agreement between UHC and Kaiser Aluminum and the policies and practices of Kaiser Aluminum and the claims administrator. The Court did not find adequate grounds to support the Motion to Dismiss and it was therefore denied.
Lastly, the Court determined that Defendant failed to satisfy its burden of proof regarding its Motion to Compel Joinder of Kaiser Aluminum. The Court opined that UHC was in as good a position as Kaiser to defend against this suit.
9. Additional Comments: The parties reached an agreement to settle both the prospective and retrospective class claims. Kaiser amended the Plan terms to provide coverage under the Kaiser Plan without the limitations described above, starting on January 1, 2016. Under the terms of the Settlement Agreement, UHC affirmed that it is administering the Kaiser Plan without limitations. See the settlement page for more details: http://www.symslaw.com/uhcsettlement/
11. Practical Implications and Lessons Learned: Case settled.
12. All Legal Theories Presented in Case: Violation of MHPAEA and breach in Defendant’s fiduciary duty
13. Successful Legal Theories in Case: Case settled.