1. Case Name: J.T. v. Regence Blueshield, United States District Court for the Western District of Washington, June 4, 2013; 291 F.R.D. 601

2. Lawyers:

  • Counsel for Plaintiff:
    • (For J.T.) Richard E. Spoonmore, Eleanor Hamburger, Sirianni Youtz Spoonemore
    • (For S.A.) Eleanor Hamburger, Sirianni Youtz Spoonemore
  • Defendant: James Derek Little, Medora A. Marisseau, Karr Tuttle Campbell

3. Format: Published Order

4. Outline: 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. S.A. was diagnosed with Developmental Articulation Disorder and Expressive/Receptive Language Disorder and neurodevelopmental treatment was requested via a phone call between Plaintiff’s mother and Defendant. Defendant relayed to Plaintiff’s mother that the therapy would not be covered. Plaintiff’s mother never sought treatment for her daughter based on Defendant’s statements that the treatment would not be covered. 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.

5. Legal Pointer: Two plaintiffs diagnosed with Developmental Articulation Disorder and Expressive/Receptive Language Disorder aim to bring a class action suit against Defendant insurer for denying coverage of neurodevelopmental speech therapy.

6. Legal Issues and Causes of Action: Plaintiffs allege Defendants actions violated the Washington Mental Health Parity Act. Defendants argue Plaintiffs lack subject matter jurisdiction to bring the claim. Plaintiff S.A. brings a motion for class certification and a motion for summary judgment. Defendant brings a motion to dismiss.

  • Ruling: The Plaintiff’s motion for class certification is denied. Plaintiff’s motion for summary judgment is denied. Defendant’s motion to dismiss is denied.

7. Narrative Case 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, finding that “…although the coverage mandate originated in phase one, it was permissible to impose certain financial limits or requirements on that coverage until full parity was achieved in phase three. What was not permissible in phase one was to completely exclude coverage for an entire class of beneficiaries.”

Defendants also allege that S.A. does not have standing to bring a claim because she has not established a redressible injury causually connected to Defendant’s actions. The Court does explain that S.A.’s requested relief has changed throughout the course of litigation, however, S.A. is found to have standing to the extent that she seeks only to enjoin Defendants from disseminating erroneous information. In this manner, she has standing as a plan beneficiary under ERISA. S.A. is also found to have standing because she alleged that any treatments for DSM-IV conditions must be covered under the mental health services benefit in order to comply with the Parity Act.

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.

8. Additional Comments: None.

9. Website: https://docs.justia.com/cases/federal/district-courts/washington/wawdce/2:2012cv00090/181362/67

10. Practical Implications and Lessons Learned: When certifying a class, it is important to carefully consider the class representative. It is unclear whether the class would have been certified had J.T. brought the motion.

11. All Legal Theories Presented in Case: Violation of Washington Mental Health Parity

12. Successful Legal Theories in Case: Violation of Washington Mental Health Parity

 

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