1. Case Name: Schoolman v. United Healthcare Ins. Co., United States District Court for the Eastern District of Missouri, Eastern Division, November 12, 2013

2. Lawyers:

  • Counsel for Plaintiff: Matthew R. Davis, Heller and Gallagher, LLP
  • Counsel for Defendant:
    • Brian R. Shank, Evans and Dixon
    • Brian W. Thompson, Donald T. Campbell, Leonard and Street

3. Format: Published Memorandum and Order.

4. Outline: 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. Plaintiff brings three counts against Defendant: Count 1 seeks recovery of benefits from Defendant, Count 2 requests equitable relief for failure to pay for the denied treatment, and finally Count 3 seeks damages based on alleged violations of the New York and Missouri mental health parity laws. This Memorandum and Order are in response to Defendant’s Motion to Dismiss Count 3.

5. Legal Pointer: Plaintiff is challenging Defendant insurer’s decision to deny his benefits for inpatient and outpatient medical care. Defendant brings this Motion to Dismiss one of the claims based on violations of state mental health parity laws based on Plaintiff’s failure to sufficiently state a basis for the claim. The Court finds that Plaintiff did fail to state a factual basis for the claim and grants Defendant’s Motion to Dismiss.

6. Legal Issues and Causes of Action: Plaintiff argues that the Defendant violated state mental health parity laws when they denied claims for both inpatient and outpatient treatment. Defendant counters this argument by stating that the Plaintiff has not included a factual basis for this claim, i.e., they have not provided any text of the policy documents stating that the benefits are not covered. Rather, Plaintiff argues that the denial in of itself is a violation of the state parity laws. Defendant successfully argues that the claims were denied because they were not medically necessary.

  • Ruling: The Court grants Defendant’s Motion to Dismiss Count III.

7. Narrative Case Description: 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.

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.

8. Additional Comments: None

9. Website: http://www.leagle.com/decision/In%20FDCO%2020131113B16/SCHOOLMAN%20v.%20UNITED%20HEALTHCARE%20INSURANCE%20COMPANY

10. Practical Implications and Lessons Learned: Plaintiffs are wise to include language from their plan documents or from the insurer itself demonstrating parity violations. Simply arguing that a denial of a claim is a parity violation will not suffice.

11. All Legal Theories Presented in Case: Violations of N.Y and Missouri mental health parity laws.

12. Successful Legal Theories in Case: None.

 

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