Legal Cases: Eating Disorders

Violation Category: Residential Treatment/Wilderness Therapy

Short Description: Plaintiff alleges that BCBSKC improperly denied reimbursement for inpatient mental health treatment that R.H. received at the Elements Wilderness Programs and Boulder Creek Academy from January 20, 2016 to March 17, 2017.

Appeal/Disposition: Defendant’s Motion for Summary Judgment was granted, and Plaintiff’s Motion for Summary Judgment was denied.

Violation Category: Wilderness Therapy Programs and Residential Treatment

Short Description: Plaintiffs initiated this lawsuit, asserting claims under ERISA and the Federal Parity Act.

Appeal/Disposition: Defendant’s Motion to Dismiss was granted without prejudice.

Violation Category: Residential Treatment

Short Description: Plaintiff, on behalf of himself and other similarly situated, alleged that Kaiser’s pattern and practice of treatment for eating disorders violated ERISA and the California and Federal Health Parity Acts.

Appeal/Disposition: Plaintiff’s medical records clearly indicated that although his treating therapist determined that he required a higher level of care, he was not amenable to a referral within the Kaiser medical system and instead elected to pursue a residential treatment program that was out of network and required out-of-pocket payment from his parents. Because Plaintiff’s therapist was willing to make a referral and the Plan did provide for residential treatment of eating disorders, Plaintiff failed to raise disputed issues of fact regarding his claim for breach of fiduciary duty. As such, Defendant’s Motion for Summary Judgment was granted.

Violation Category: Partial Hospitalization for Eating Disorder Treatment

Short Description: Ariana M. sued Humana Health Plan of Texas, Inc. alleging that Humana had wrongfully denied benefits for 106 days of partial hospitalization to treat an eating disorder. Humana had paid for 49 days of partial hospitalization before determining that Ariana M. did not meet the criteria for continued coverage at that level. Instead, she was covered for the next level of care (Intensive outpatient). The U.S. District Court for the Southern District of Texas granted summary judgment for Humana, holding that it did not abuse its discretion in denying the benefits. Ariana M. appealed. On appeal, the Fifth Circuit acknowledged that its standard of review for ERISA cases was at odds with that of most circuits and changed the law. The Fifth Circuit held that district courts are to review <em>de novo </em>a plan administrator’s decision to deny coverage under an ERISA plan. The Fifth Circuit vacated the order granting summary judgment and remanded for the District Court to apply the <em>de novo.</em>

Appeal/Disposition: Humana’s Motion for Summary Judgment and Motion to Strike were granted and Ariana M.’s Cross-Motion for Summary Judgment and Motion for Attorneys’ Fees were denied.

Violation Category: Residential Treatment

Short Description: Appellant appealed the district court’s judgment in favor of the United Healthcare Insurance Company, affirming denial of benefits. Appellant contends that United’s denial was not supported by the record and was contrary to the guidelines used both by United and treating professionals in the mental health field.

Appeal/Disposition: The district court did not err when determining whether Appellant’s stay at Sierra Tucson was medically necessary as covered by the Plan. Appellant failed to show by a preponderance of the evidence that the treatment she received ay Sierra Tucson was medically necessary or in compliance with United’s applicable guidelines.

Violation Category: 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.

Short Description: The motion before the Court for limited discovery is based upon Plaintiff’s argument that the administrative record lacks any documentation about the potential conflict of interest between UBH and Oxford relating to the claims process. Plaintiff argues that the Court should permit to her to conduct discovery to determine if the insurance company’s experts and doctors were independent. The Court agrees with Plaintiff’s argument and grants Plaintiff’s Motion.

Appeal/Disposition: The Court grants Plaintiff’s Motion for Limited Discovery but denies to grant the request for a deposition of Defendant’s designated representative.

Violation Category: 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.

Short Description: 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.

Appeal/Disposition: The Court grants Defendant’s Motion to Dismiss Count III.

Violation Category: In-patient treatment at a residential treatment facility was denied due to plan exclusion.

Short Description: Plaintiff’s daughter was admitted to a hospital on the verge of heart failure due to an eating disorder. After being discharged, she was later readmitted three times. Treating providers recommended additional residential treatment due to “severe medical risk.” United told plaintiffs that the policy did not cover inpatient treatment at residential treatment facilities, and denied payment because of this exclusion in the policy. The Plaintiffs assert that United’s policy excluding residential treatment services violates Nebraska parity law. The Plaintiffs brought their claims under ERISA and Nebraska state law. United filed a motion to dismiss these claims stating that the Nebraska parity law is preempted by (overridden by) ERISA, that Nebraska law does not require coverage of the services the daughter received, and that the policy does not require coverage for the treatment the daughter received, among other reasons. United also filed a motion to dismiss Jane Wedekind as a plaintiff arguing that Jane Wedekind lacks standing. The district court found that Nebraska state law was not preempted by ERISA because it is a state statute that mandates certain benefit terms and thereby regulates insurance. As such, the court determined that the Nebraska state parity law for mental illness requires coverage for treatment at residential treatment facilities, and that the policy may allow for coverage for treatment at the center where the daughter was treated. The court found that Jane Wedekind does not have standing.

Appeal/Disposition: Defendant’s motion to dismiss was denied.

Violation Category: There are four named Plaintiffs: Beye, Byram, Drazin and Sedlak. Three of the Plaintiffs’ policies cover treatment for biological based mental illness (BBMI) at parity with other illnesses, as required by the New Jersey Mental Health Parity Law. Three policies also contain limitations for non-BBMIs (Byram, Beye and Drazin). Plaintiffs Beye and Drazin received coverage for the eating disorders as non-BBMIs but exhausted coverage. Plaintiffs Byram and Sedlak’s claims were denied as not medically necessary.

Short Description: The Court first considers whether to abstain from considering Plaintiffs claims pursuant to the holding of Burford v. Sun Oil Co. Relying upon the holding in DeVito v. Aetna, the Court decides that abstention is not appropriate in this case. The Court then considers whether to dismiss the claims of Plaintiff Byram, Beye and Sedlak for failure to appeal their adverse IURO decisions to the appellate division but find that beneficiaries of ERISA plans are not required to appeal an adverse IURO ruling before filing suit. Likewise, non-ERISA plaintiffs are required to appeal adverse IURO rulings before filing suit. Next, the Court considers whether to dismiss all claims brought by Plaintiffs Byram and Sedlak whose claims were deemed not medically necessary. The Court states that the Plaintiffs must demonstrate a connection between the claims and the Defendant’s improper treatment of eating disorders, but that dismissal at this stage is not appropriate. The Court then considers whether ERISA preempts the common law and state claims. The Court holds that based on the language, the ERISA plaintiffs may pursue their contractual claim to benefits but that the Parity Law claims are dismissed and preempted. The Court then moves on to the Plaintiffs Parity Law Claims. The Plaintiffs argue for an implied private cause of action. The Court disagrees and grants Defendant’s motion to dismiss these claims. In so deciding, the Court considers the test for whether a statute provides an implied cause of action, “whether: 1) the Plaintiff is a member of the class for whose special benefit the statute was enacted, 2) there is any evidence that the Legislature intended to create a private right of action under the statute, and 3) it is consistent with the underlying purposes of the legislative scheme to infer the existence of such a remedy.”

Appeal/Disposition: The Defendants motion to dismiss is denied in part and granted in part.

Violation Category: Plaintiffs DeVito and Meiskin have daughters who suffer from eating disorders. Plaintiff Meiskin’s daughter’s coverage was cut off when it exceeded the contractual limitations for coverage of non-biologically based mental illness

Short Description: Defendants argue that Plaintiffs state law claims are preempted under ERISA § 502(a) and §514(a). The Court notes that Plaintiffs appear to allege a private right of action under the NJ Parity Act. In finding that the claims are, in fact, preempted by ERISA, the Court states that the savings clause does not preclude preemption and that because Plaintiffs could have brought their claim under ERISA and there is no other independent legal duty implicated by the Defendants actions that the claims are properly preempted.

Appeal/Disposition: The Defendant’s motion to dismiss was granted as to the Parity Law claim and the punitive damages claim but otherwise denied.