• Filing. Published in U.S. District Court for the District of Utah on April 2, 2020 (Case no. 2:18-cv-00710-DBB-CMR).
  • Plaintiffs were enrolled in a fully insured health plan where United ran the plan and service as the TPA.  The Plaintiff’s dependent received treatment at three Utah-based and licensed “subacute treatment” (aka residential treatment centers) and wilderness therapy facilities for adolescents.  Reimbursement for the care was denied at all three facilities due to a lack of medical necessity.  In one case United wrote the treatment records “indicated the absence of continued acute impairment of behavior or cognition that interfered with her activities of daily living to the extent that her welfare or that of others was endangered.” The denial of care was upheld during the appeals, and for one appeal United said they did not have a record of that appeal.

Plaintiffs have filed an amended complaint and are bringing an action based on a breach of fiduciary duty under ERISA’s 1132(a)(1)(B) and for a Parity Act violation claim under ERISA 1132(a)(3).  Defendant United has filed a 12(b)(6) motion to dismiss based on: 1) United is not the proper party defendant; and 2) failure of Plaintiffs to allege facts sufficient to support the Parity Act violation.

  • Holding. Judge David Barlow writes that the Plaintiffs have sufficiently pled their case and refused to rule on whether United or Oxford at this juncture was the proper defendant to this action because a “motion to dismiss does not authorize ‘piecemeal dismissals of parts of claims.”  But the court did dismiss the Parity Act claim
  • Analysis. The Court wrote:

Plaintiffs asserting an as-applied claim for discrimination generally must do more than state conceptually that they were treated worse than others. They must allege facts showing how that happened. In other words, they must plead facts involving actual, real-world, discrimination, not just a theoretical possibility. Like other claims involving discrimination, Parity Act claims are necessarily comparative. For example, to plead discrimination under Title VII, plaintiffs must allege facts suggesting that they were treated differently and worse than others who were similarly situated. In other words, plaintiffs must allege facts about their own experience and they must allege facts regarding similarly situated employees who were treated differently….

Plaintiffs’ ‘general assertions’ of differential treatment, ‘without any details whatsoever’ of how Defendant treated comparator medical claims, are ‘insufficient to survive a motion to dismiss.’