1. Case Name: Wilson v. Anthem Health Plans of Ky., U.S. District Court for the Western District of Kentucky
2. Type of Treatment Services Denied: Plaintiff’s son’s Applied Behavior Analysis (ABA) treatment for his autism spectrum disorder (ASD) was denied.
- Plaintiff: Robert R. Sparks, Strauss Troy Co., LPA
- Defendant: Darryl William Durham, Weber & Rose, PSC; Martin J. Bishop, Rebecca R. Hanson, Reed Smith LLP
4. Format: Memorandum Opinion and Order on Class Certification
- ERISA Claim? Yes.
- Class Action/or Individual Action: Action centers on motion seeking class certification
- Defendant: Defendant is insurer
- Type of Insurance Plan: Not specified
- Type of Coverage Denial: Both medical necessity and administrative.
6. Legal Pointer:
7. Legal Issues and Causes of Action: The matter before the Court is a Motion for Class Certification and a Motion to Strike Undisclosed Evidence and Testimony.
- Ruling: The Motion for Class Certification is granted.
8. Narrative Case Description: Plaintiff is the mother of a minor child with ASD. Plaintiff’s son received ABA at a treatment facility in Kentucky. The treatment was aimed at progressing in the areas of communication, cognition and activities of daily living. Defendant health plan provided coverage for ASD and ABA, but placed limitations on the coverage. Defendant denied portions of Plaintiff’s claims resulting in tens of thousands of dollars of care that was not reimbursed.
Defendant limits treatment for ASD to 1,000 hours per year for individuals aged 1-7, and 20 hours per month for individuals aged 7-21. Defendant also imposes dollar limitations but argues that these limitations do not violate ERISA nor MHPAEA. Plaintiff argues that the Defendant does not impose similar limitations on medical and surgical benefits and does in fact operate in violation of MHPAEA.
Defendant argues against class certification in that 1) “under state and federal law, ASD may or may not be a mental health condition, depending on the individual,” and 2) “whether ABA therapy is a ‘mental health benefit’ is also not a question that could be answered on a class-wide basis but rather requires individualized determinations.
The Court certifies the class, finding that the Rule 23 prerequisites of numerosity, commonality, typicality and adequate representation have been met. Of note, the Court finds that the 27 class members are sufficient to grant class certification. Case law has suggested that a class of 20 or fewer is generally insufficient to grant class certification. The Court also found that the question of commonality has been met as the overarching common question of law in this case is whether “Anthem [may] legally limit benefits for the treatment of ASD if it does not have similar limits for medical/surgical benefits.”
9. Additional Comments: The discussion on adequacy of counsel is useful. Additionally, the Court’s emphasis on a “unitary course of conduct,” “failing to use an adequate process,” and a “single course of wrongful conduct” is useful in pivoting away from individualized issues.
11. Practical Implications and Lessons Learned: The case has several important points to note: 1) the class was certified; 2) the case involves ERISA; 3) the court found that 27 class members is sufficient; 4) the class rep had a high amount of out of pocket expenses – this did not impact class certification (insurance companies often say that only small amounts of out of pocket expenses are suitable for class treatment, the Court rejected this); 5) the case challenged caps on ABA treatment
12. All Legal Theories Presented in Case: Violations of MHPAEA and ERISA
13. Successful Legal Theories in Case: Violation of MHPAEA