“Plaintiffs allege the Plan’s exclusion for wilderness programs violates the Parity Act because the exclusion, by the terms of the Plan, applies only to mental health and substance abuse benefits. Indeed, a review of the Plan confirms as much. The Plan contains references to wilderness programs in only two places. The first is in the section listing exclusions related to mental health services. The second is in the section listing exclusions related to substance abuse treatment. No such reference is contained in the sections listing exclusions related to specific medical or surgical benefits…”
The judge concluded that was a sufficient pleading of facts to avoid a dismissal motion that the plan could have violated “the Parity Act because a wilderness program exclusion applies to treatment at intermediate level mental health and substance abuse facilities but not to analogous intermediate level medical/surgical facilities.”
However, the court wrote that the Plaintiff failed to adequately plead a Parity Act violation with respect to J.E.’s treatment at Cascade because the pleading did not explain why the “custodial care” exception just took place for MH/SUD care. The judge noted “The Complaint does not identify any specific treatment limitation that (the plan) applied to J.E.’s Cascade claims that it would not apply to medical/surgical claims.”
The court further explained why the ERISA 1132(a)(1)(B) recovery of benefits action; and 2) an ERISA 1132(a)(3) Parity Act violation claims are not redundant. The latter includes equitable relief that is not provided in the former. Even if the Plaintiffs’ monetary injury is addressed, Plaintiffs’ injury of being subject to a plan whose coverage is violative of the Parity Act would remain unremedied.