Legal Cases: Other

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: Residential Treatment

Short Description: Mike and Maddie filed their single-count Complaint seeking recovery of benefits under 29 U.S.C § 1132(a)(1)(B). Under Count One, Plaintiffs also alleged that Anthem breached its fiduciary duties under 29 U.S.C. § 1104 and § 1133 by failing to act solely in the interest of the Plan participants and beneficiaries when it denied Maddie’s benefits and by failing to provide a full and fair review as required under the Plan and by ERISA.

Appeal/Disposition: Plaintiffs sought judgment in the amount of $200,000.00, plus prejudgment interest pursuant to Utah Code Ann. § 15-1-1, and attorney fees and costs incurred under 29 U.S.C. § 1132(g). The court held oral argument on the motions and, on the basis of that hearing, the parties’ briefs, and a review of the relevant law, the court granted in part and denied in part Anthem’s Motion for Summary Judgment and granted in part and denied in part Plaintiffs’ Motion for Summary Judgment.

Violation Category: Residential Treatment

Short Description: The parties filed cross-Motions for Summary Judgment. Plaintiffs sought review of Premera’s denial of benefits under the plan. Specifically, Premera declined to cover a portion of Lillian R.’s stay at a residential treatment center as not medically necessary. Plaintiffs repeatedly appealed Premera’s decision, but at each level of review, the denial was affirmed. Plaintiffs therefore filed suit in an effort to recover the denied benefits.

Appeal/Disposition: Based on the Court’s review of the record and its consideration of the parties’ arguments, the Court concluded that Lillian R.’s residential treatment at issue was medically necessary and therefore covered under the plan. Judgment was entered in favor of the Plaintiffs.

Violation Category: Residential Treatment

Short Description: Plaintiff filed suit against Companion Benefit Alternatives, Inc. (CBA) for plan enforcement under 29 U.S.C. § 1132(a)(1)(B) and violation of the Parity Act. Defendant filed a Motion to Dismiss.

Appeal/Disposition: Defendant’s Motion to Dismiss the Amended Complaint was granted, and the case was dismissed without prejudice.

Violation Category: Residential and Intensive Outpatient Treatment

Short Description: Plaintiffs contend that Defendants violated legal and fiduciary duties they owed to health insurance plan participants and beneficiaries by improperly restricting the scope of their insurance coverage for residential and intensive outpatient mental health and substance abuse treatment. Plaintiffs further alleged that these restrictions were inconsistent with the terms of the relevant insurance plans and generally accepted professional standards in the mental health and substance abuse disorder treatment community.

Appeal/Disposition: Plaintiffs’ unopposed Motion for Settlement was granted.

Violation Category: Residential Treatment

Short Description: Plaintiff brought this action under ERISA, challenging Defendant’s denial of mental health benefits for residential treatment services provided for his 17-year-old son, C.M.

Appeal/Disposition: Plaintiff’s motion for summary judgment was granted to the extent that the Court found that the Plan’s provision excluding coverage for residential treatment services violated the Parity Act. Defendant’s motion for summary judgment was granted as to the Complaint’s Second Claim of Relief, but was otherwise denied. The Court reserved decision as to the appropriate remedy for Defendant’s statutory violation, pending additional briefing. This case later settled.

Violation Category: In-patient treatment for depression and polysubstance dependence

Short Description: Plaintiffs alleged that BCBS improperly denied mental health benefits for treatment received at two in-patient treatment facilities. Plaintiffs filed a Petition for Damages, Penalties and Attorney’s Fees.

Appeal/Disposition: Plaintiffs’ Petition was dismissed with prejudice at Plaintiffs’ costs.

Violation Category: In-Patient Wilderness Treatment Program

Short Description: Plaintiff’s son struggled with mental health issues such as early childhood trauma, complex post-traumatic stress disorder, attention deficit hyperactivity disorder, depression, low self-esteem and drug use. In February 2015, his therapist concluded that he was no longer treatable in an out-patient setting, and recommended intensive, in-patient treatment. He was transmitted to Second Nature Therapeutic Wilderness Program, a mental health service provider based in Utah. Plaintiff sought coverage under the NextEra health and welfare benefits plan, which was denied.

Appeal/Disposition: Plaintiff did not exhaust all available administrative remedies before filing suit and did not put forth any “clear and positive showing of  futility” and otherwise persuade the Court that he should be excused from the administrative exhaustion requirement. Plaintiff’s case is dismissed with prejudice. The time for Plaintiff to exhaust his administrative remedies expired, due to no fault of Cigna. Therefore, Plaintiff was not able to refile his ERISA claims against Cigna based on the denial of coverage referenced in the Second Amended Complaint.

Violation Category: Transcranial Magnetic Stimulation (“TMS”) for treatment of depression

Short Description: Plaintiff filed suit for the denial of TMS for the treatment of depression.

Appeal/Disposition: This case settled.

Violation Category: Non-restorative speech therapy treatment (neurodevelopmental therapy)

Short Description: In 2006, Defendant Group Health diagnosed Z.D. with two DSM-IV-TR mental health conditions: a “moderate-severe receptive language disorder” and “other specific developmental learning disabilities.” At the time of her diagnoses, Z.D. began receiving covered non-restorative speech therapy treatment for her conditions. Circumstances changed, however, shortly before Z.D.’s seventh birthday. Plaintiff was told that, per the Plan, non-restorative speech therapy treatments were not covered for individuals over the age of six and thus her treatments would no longer be covered once she turned seven.

Appeal/Disposition: Defendants were ordered to cease denying coverage for medically necessary neurodevelopmental therapy to treat insureds with DSM-IV-TR mental health conditions simply because the insured was over six years old. Defendants were also ordered to cease their application of any treatment limitations that are not generally “imposed on coverage for medical and surgical services.”