Legal Cases: Suicidal Ideation / Attempts

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: 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 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: 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: Plaintiff is the adult child of an employee of Indiana University who struggles with mental health disorders, including suicidal ideation and self-harm. Plaintiff brings this individual action against Defendant large employer health insurance plans that denied over $100,000 worth of insurance claims for Plaintiff’s care at several inpatient facilities including mental-health hospitals and non-hospital specialized inpatient facilities. The denials were not based on medical necessity but rather a categorical exclusion in the health plan denying coverage for residential treatment care. Plaintiff argues the categorical exclusion violates federal and state mental parity laws, anti-discrimination laws and breaches plan contracts.

Short Description: Plaintiff alleges that Defendant’s actions violated federal and state mental health parity laws, anti-discrimination laws and breach of contract. Plaintiff filed a motion to proceed under a fictitious name which is the basis of the memorandum. Defendants argue that proceeding under a fictitious name would prejudice their defense. Here, the Court found that the Plaintiff could move forward under the false name due to the substantial risk of physical and mental harm that could result. Defendants argued that their defense would be hindered in that Plaintiff must prove that Plaintiff is an individual with a disability and that Defendants intentionally discriminated against Plaintiff. However, the Court found that Defendants had not argued any facts on how the Plaintiff’s anonymity would hinder the defense. The Court did find that the Plaintiff did not show a need to seal Plaintiff’s gender or nature of the mental illness involved in the case and cautioned that the balancing of the interests could shift as the case progressed.

Appeal/Disposition: This specific case dealt with whether the Plaintiff could use a fictitious name and a motion to maintain seal of un-redacted affidavit from her psychiatrist. Those motions were granted in part and denied in part.

Violation Category: The Plaintiff provided inpatient psychiatric care under Idaho’s Medicaid program. Defendant denied at least some portion of Medicaid reimbursement in all three cases. The Plaintiff appealed the decision to deny reimbursement and filed petitions for judicial review. The district court reversed the decisions of the Defendant and ordered reimbursement in full in all three cases.

Short Description: Four issues are argued on appeal: 1) whether Plaintiff has standing to assert the due process rights of its patients; 2) whether Idaho documentation requirements conflict with federal certification requirements; 3) whether the hearing officer’s preliminary orders were supported by substantial evidence; and 4) whether Defendant is entitled to an award of attorneys fees and costs.

Appeal/Disposition: On appeal, the court affirmed that the care was properly denied because the record lacked documentation sufficient to demonstrate the medical necessity criteria. This seems to indicate that the lack of supporting evidence in a medical record, rather than the opinion of the medical professionals treating J.M., was the cause of the denial of care