Legal Cases: Other - Page 2

Violation Category: Psychiatric treatment in residential treatment center for major depressive disorder

Short Description: Plaintiff seeks to end Microsoft’s discriminatory practice of excluding all coverage from the Plan for psychiatric treatment in residential treatment centers (except for treatment of eating disorders). S.S. was diagnosed with major depressive disorder and required treatment from a residential treatment center. S.S. had to pay for treatment received from the residential treatment center out of pocket. S.S. completed the internal appeal process and exhausted her administrative remedies.

Appeal/Disposition: The Court granted Defendants’ Motion to Dismiss. Plaintiff appealed but later voluntarily dismissed the appeal.

Violation Category: Long-term residential treatment services for depression

Short Description: Plaintiffs filed suit against Sinclair Services Company and Sinclair Services Company Point of Service Basic Plan after Sinclair’s Plan Administrator denied the family’s claim for benefits relating to long-term residential treatment services rendered to the family’s minor daughter, N.F., for depression. Plaintiffs argued it was due benefits under the Plan for two reasons: first, the Administrator abused its discretion when it denied the F. Family’s claim for benefits incurred before January 1, 2013, based on an unreasonable interpretation of the Plan’s terms and second, the family was entitled to benefits incurred on or after January 1, 2013, because the 2013 amendment to the Plus Plan excluded coverage for residential treatment services violated the Party Act.

Appeal/Disposition: The F. Family and the Plan Administrator cross-moved for summary judgment on the F. Family’s claim for benefits. Both Motions were granted in part and denied in part. The Court remanded the matter to the Administrator.

Violation Category: Treatment limitations on ABA therapies for ASD and treatment limitations for NDT therapies for pervasive developmental disorder-not otherwise specified and developmental delays

Short Description: Plaintiff alleged that Premera adopted a uniform policy excluding coverage for neurodevelopmental therapy (NDT) to treat DSM conditions for individuals over the age of six and imposed visit limits on such therapies when covered under its “rehabilitation” benefit. Plaintiff further alleged that he was denied coverage for speech and occupational therapy necessary to treat his DSM condition of pervasive developmental disorder-not otherwise specified and developmental delays after reaching visit limits under his rehabilitation benefit. Plaintiff contended that to the extent that Premera provided any coverage of NDT or ABA therapies, it generally imposed treatment limitations that were not at parity with coverage for medical and surgical services.

Appeal/Disposition: The Court granted Plaintiff’s Motion for Preliminary Approval of the class settlement.

Violation Category: Coverage for physical and occupational therapies was denied because the purpose of the therapy was to achieve development beyond any level of functioning that E.D. had previously demonstrated

Short Description: E.D. was born with agenesis of the corpus collosum. E.D. was “often defiant, hostile, and oppositional toward both parents and suffers from over-stimulation, anxiety, anger, and frustration. E.D. struggles to build close relationships with others, has no close friends, and often alienates her peers. E.D. seeks sensory gratification by chewing gum and ‘constantly hugging’ her mother. E.D. has low muscle tone in the trunk area and spine curvature which causes her stomach to “pop out” and her back to “sway in”. E.D. has problems with balance and strength, complains of fatigue and back pains when engaging in simple physical activity such as a short walk or sitting for long periods of time. She will eat constantly unless someone intervenes – at the time of the hearing, E.D. was 13 years old, five foot three inches tall and weighed at least 190 pounds.” The Plaintiff appealed to a first level appeal (confirmed the denial), then to the Commission (upheld the denial), which was then appealed to an Administrative Law Judge (ALJ). The final decision was made by the Commission which reaffirmed its prior decision to deny benefits. The ALJ found that E.D. was entitled to coverage because her ACC is a BBMI and the non-restorative clause within the contract was ambiguous. In reviewing the decision, the Court will not reverse unless the decision was arbitrary, capricious or unreasonable; violates express or implied legislative policies; offends the State or federal Constitution; or the findings on which it is based are not supported by substantial, credible evidence. In deciding whether the decision was based on substantial, credible evidence, the Court states that the testimonies of both Dr. Yee and Dr. Leech were properly admitted. However, there was insufficient credible evidence to support the finding by the Commission that ACC is a BBMI. The Court remands the case back for further proceedings specifically related to whether ACC is a BBMI.

Appeal/Disposition: The Court reversed and remanded the denial back to the trial court.