1. Case Name: C.M. v. Fletcher Allen Health Care, Inc., United States District Court for the District of Vermont, April 30, 2013
2. Type of Treatment Services Denied: Outpatient treatment
- Counsel for Plaintiff: Alison J. Bell, Langrock Sperry & Wool, LLP
- Defendant: Linda J. Cohen, W. Scott Fewell, Dinse Knapp & McAndrew, P.C.
4. Format: Entry order granting in part and denying in part Defendants’ Motion to Dismiss
5. Outline: Plaintiff is a 25-year-old that suffers from mental illness. Plaintiff brings this individual action against Defendant Fletcher Allen as plan administrator. Defendant contracts with Vermont Managed Care Inc. to administer claims for medical benefits and with CIGNA Behavioral Health to administer claims for mental health benefits.
Plaintiff engaged in outpatient psychotherapy four times per week. This treatment was initially covered. At a later date, Plaintiff’s physician received a letter that if claims exceed 25 sessions that a case review would be conducted and prior authorization would be required for future sessions. Defendant did not conduct a case review until more than 6 months later and found that the treatment was not medically necessary.
Plaintiff argued that Defendant violated MHPAEA in that the Plan’s written policies and actual practices contained different standards for mental health benefits than for medical/surgical benefits.
6. Legal Pointer: Plaintiff argues that Defendant’s policies and practices violated MHPAEA in that pre-approval, concurrent reviews, and an automatic review process are not required for medical and surgical services but are required, or at least imposed, for mental health services. In practice, mental health claims were subject to these reviews.
7. Legal Issues and Causes of Action: Plaintiff alleges that the Plan’s written policies and actual practices violate MHPAEA in that they apply different standards to mental health benefits than medical/surgical benefits. Plaintiff presents six counts: 1-3 argue that Defendant violated MHPAEA by imposing more stringent reviews for mental health benefits than for medical benefits; count 4 alleges that the Plan waived its right to conduct a pre-approval of prospective review when the treatment was covered by Defendant for more than 6 months; count 5 alleges that Plaintiff met the criteria for medical necessity and that Defendant’s denial was arbitrary and capricious; and finally, count 6 alleges that Plaintiff’s mother was the victim of retaliation due to Plaintiff bringing this action. Defendant brings a motion to dismiss all counts.
- Ruling: Defendant’s motion to dismiss is denied in part and granted in part.
8. Narrative Case Description: Plaintiff engaged in outpatient psychotherapy sessions four times per week beginning in January 2011. In late February, CIGNA (Defendant’s contractor) sent a letter to Plaintiff’s physician stating that “should claims exceed 25 sessions, a case review based on medical necessity will be necessary.” CIGNA did not conduct a case review until June 7, 2011 at which time CIGNA determined that the treatment was not medically necessary. Plaintiff brought six counts alleging violations of MHPAEA. Defendant brought a Motion to Dismiss.
In her counts 1-3, Plaintiff alleges that Defendant violated MHPAEA by imposing more stringent reviews for mental health benefits than for medical/surgical benefits. Defendant argued that the Plan documents contain evidence that they do not violate MHPAEA. Defendant also argued that it is Plaintiff’s burden to establish a difference between the Plan terms and clinically appropriate standards of care. The Court disagreed that it is the Plaintiff’s burden to demonstrate that difference and states that it is the burden of the plan administrator to demonstrate why these benefits are treated differently. Thus, the Court denies Defendant’s motion as to counts 1-3.
In count 4, Plaintiff alleges that the Plan waived its right to conduct a pre-approval or prospective review of her treatment when it failed to do so until June 2011, after covering the treatment for more than six months. The Court disagrees with Plaintiff’s argument citing that ongoing medical necessity reviews of outpatient mental health services are expressly provided for in the Plan’s terms. The Motion to Dismiss Count 4 is granted.
In count 5, the Plaintiff argues that she satisfied the criteria for medical necessity and thus that the denial of her benefits was arbitrary and capricious. In response, Defendant argued that this claim is preempted as Plaintiff did not exhaust the internal appeal process. Plaintiff did not challenge benefit denials after December 7, 2011. Plaintiff stated that she is not asking the court to make medical necessity determinations as to post-December 7, 201 claims but rather she is asking the court to interpret MHPAEA. The Court denies Defendant’s Motion to Dismiss count 5 as moot.
Finally, the court considers count 6 where Plaintiff argues that her mother was retaliated against when Plaintiff brought this suit. However, Plaintiff does not argue sufficient facts to show that she can bring a claim on behalf of her mother – she does not allege an obstacle that prevented her mother from bringing her own claim. Thus, Defendant’s Motion to Dismiss is granted as to count 6.
9. Additional Comments: None.
11. Practical Implications and Lessons Learned: Simply requesting the Court to read the plan documents is not sufficient to defend against a violation of MHPAEA. Had the Defendant done a better job of building out this defense, it is unclear whether they would have had more success or not.
12. All Legal Theories Presented in Case: Violation of MHPAEA
13. Successful Legal Theories in Case: Violation of MHPAEA