1. Case Name: J.S. v. State Health Benefits Com’n, Superior Court of New Jersey, Appellate Division, March 4, 2010.

2. Type of Treatment Services Denied: Plaintiff’s claims for treatment for physical and occupational therapy to treat agenesis of the corpus callosum (ACC) were denied.

3.Lawyers:

  • Counsel for Plaintiff: Disability Rights New Jersey (Susan Saidel, on the brief)
  • Counsel for Defendant: Paula T. Dow, Acting Attorney General, Lewis A. Scheidlin and Jeff S. Ignatowitz, Deputy Attorneys General

4. Format: Unpublished opinion per curiam

5. Outline:

  • ERISA Claim? No.
  • Class Action/or Individual Action: Individual action.
  • Defendant: Plaintiff is covered under NJ PLUS which is established within the Defendant’s organization and administered by Horizon.
  • Type of Insurance Plan: State run insurance plan – NJ PLUS
  • Type of Coverage Denial: Administrative
  • Causes of Action: Plaintiff argues that the denial of benefits violates the New Jersey Mental Health Parity Act.

6. Legal Pointer: This case largely focuses on two central points. The first is that the plan has a categorical exclusion of services or supplies that are rendered with the primary purpose of promoting development beyond a level previously demonstrated. The second is the categorization of ACC as a non-biologically based mental illness (BBMI), and thus not subject to parity. The Plaintiff disputes both of these arguments.

7.Legal Issues and Causes of Action: The Plaintiff alleges that Defendant’s actions violate the New Jersey Mental Health Parity Act.

  • Ruling: The court reverses the administrative decision to deny benefits and remands for further proceedings. Specifically, the Commission must consider whether ACC is a BBMI.

8. Narrative Case Description: Plaintiff J.S. filed the motion on behalf of her minor daughter, E.D., who was born with ACC. Plaintiff requested preauthorization for physical and occupational therapy which was denied. The Plaintiff appealed to a first level appeal (confirmed the denial), then to the Commission (upheld the denial), which was then appealed to an Administrative Law Judge (ALJ). The final decision was made by the Commission which reaffirmed its prior decision to deny benefits. The ALJ found that E.D. was entitled to coverage because her ACC is a BBMI and the non-restorative clause within the contract was ambiguous.

The question of whether ACC is a BBMI is important because the NJ Parity Law required parity for BBMIs.

The ALJ based its holding that ACC is a BBMI based on the testimony of Dr. Leech, a psychologist with 25 years of experience. She also testified that the symptoms of ACC experienced by E.D. are typically treated with physical and occupational therapy.  Her testimony was countered by Dr. Yee, a medical doctor who had no experience with ACC.  Dr. Yee testified that ACC is not a BBMI.

Ultimately, the Commission found that the only medical expert, Dr. Yee, who testified at the hearing stated that ACC is not a BBMI and therefore, not subject to parity.

In reviewing the decision, the Court will not reverse unless the decision was arbitrary, capricious or unreasonable; violates express or implied legislative policies; offends the State or federal Constitution; or the findings on which it is based are not supported by substantial, credible evidence. In deciding whether the decision was based on substantial, credible evidence, the Court states that the testimonies of both Dr. Yee and Dr. Leech were properly admitted. However, there was insufficient credible evidence to support the finding by the Commission that ACC is a BBMI. The Court remands the case back for further proceedings specifically related to whether ACC is a BBMI.

9. Additional Comments: The Court distinguishes its holding from Micheletti and Markiewicz where the conditions were specifically defined as BBMIs in the statute.

10. Website: http://law.justia.com/cases/new-jersey/appellate-division-unpublished/2010/a1214-08-opn.html

11. Practical Implications and Lessons Learned: This case presents an example where a categorical exclusion is not necessarily condemned to fail. The express question is whether ACC qualifies as a BBMI.

12. All Legal Theories Presented in Case: Violation of NJ Mental Health Parity

13. Successful Legal Theories in Case: None

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