Legal Cases: Unspecified Diagnosis

Violation Category: Residential Treatment

Short Description: Plaintiffs sought to recover benefits for Kirstyn’s residential treatment.

Appeal/Disposition: The Court agreed with Aetna that because New Haven does not meet the Plan’s definition of a Residential Treatment Facility, and because Plaintiff failed to obtain pre-certification as required, Plaintiffs’ claim for coverage at New Haven was properly denied. Defendants’ Motion for Summary Judgment was granted.

Violation Category: Outpatient, in-network mental health office visits for an unspecified mental health disorder

Short Description: Plaintiff alleged that the limits placed on mental health office visits by her health care plan violated the MHPAEA and that Defendant breached its fiduciary duty by enforcing it. Plaintiff sought to certify a class of other individuals enrolled in large, self-funded plans administered by UHC and requested, on behalf of the class: an Order declaring that visit limits on mental health services are void and unenforceable; UHC be permanently enjoined from including similar plan provisions in the future or from applying such terms if they appeared in other plans; and an Order requiring UHC to provide “accurate information concerning mental health coverage in all class members’ plans.”

Appeal/Disposition: Defendant’s Motion for Judgment on the Pleadings or, in the alternative, to Compel Joinder of a Necessary Party was denied. The case later settled.

Violation Category: Inpatient detoxification for unspecified disorder

Short Description: Plaintiff’s son received inpatient detoxification treatment at the behest of his physicians. Plaintiff argued a systematic violation of MHPAEA and requested class certification. The Defendant no longer provides any claims administration and does not administer any commercial health plans, thus rendering moot the Plaintiff’s claims. Additionally, Defendant argues that the individualized monetary damages are the only remedy that Plaintiffs seek and that this is improper for the Court to address in a class certification.

Appeal/Disposition: Plaintiff’s motion for class certification is denied, Defendant’s motion to deny class certification is granted.

Violation Category: Out-of-network inpatient treatment for an unspecified mental health disorder.

Short Description: Plaintiff’s father sought prior authorization for Plaintiff to be treated at an out-of-network treatment center. Without prior authorization, Plaintiff would be required to pay all costs out of pocket. Plaintiff sought prior authorization for more than 2 weeks. Defendant never approved, nor denied the claim. Plaintiff filed suit and argues breach of the covenant of good faith and fair dealing, breach of contract, fraudulent concealment, anticipatory breach of contract, violations of the Affordable Care Act (ACA) and MHPAEA

Appeal/Disposition: Defendant’s motion to strike is granted. Defendant’s motion for judgment on the pleadings is denied as to the breach claim and granted as to all others. Plaintiff’s motion to amend their complaint is granted as to the breach claim and denied as to all others. Plaintiff’s claims for fraudulent concealment, anticipatory breach of contract, and failure to comply with the ACA and MHPAEA are dismissed with prejudice.

Violation Category: Reimbursement for various treatments

Short Description: :A polyglot group of unrelated plaintiffs who ether 1) applied to their employer-sponsored health plan for reimbursement of the cost of mental health care or substance abuse treatment, or 2) provided mental health care for which their patients were not fully reimbursed by their employer-sponsored health plans. In each instance, Defendants had something to do with the denial of benefits sought. Plaintiffs seek money damages and an injunction requiring United to treat mental health or substance abuse benefits no less favorably than it treats medical or surgical benefits when it assesses whether claims are reimbursable under various employer-sponsored health plans.

Appeal/Disposition: United moved to dismiss all claims asserted, arguing that every plaintiff failed to state a claim against it and that the NYSPA lacks standing to pursue any claim. Plaintiffs cross-moved for a preliminary injunction, seeking to enjoin United’s practices that allegedly violate mental health parity laws. As to all claims, the motion to dismiss was granted.

Violation Category: Reimbursement for various treatment.

Short Description: Please see N.Y. State Psychiatric Ass’n, Inc. v. Unitedhealth Grp (2013) for background on the lower court’s holding. Plaintiffs appealed the lower court’s findings.

Appeal/Disposition: The Court affirmed the dismissal of Dr. Menolascino’s claims. The Court vacated and remanded remaining portions of the case for further proceedings.

Violation Category: Reimbursement rates

Short Description: Plaintiffs, a collection of individuals, doctors and professional associations, allege in their Second Amended Complaint that Defendants utilize methodologies to determine insurance reimbursement rates for mental health services that are not comparable to those Defendants utilize in determining reimbursement rates for medical and surgical services in breach of their fiduciary obligations to their plan holders under the Parity Act and ERISA. Plaintiffs also allege that, in doing so Defendants have breached contracts between Anthem and the doctors, which prohibit Anthem from discriminating against patients on the basis of their health status, and that Anthem has tortuously interfered with the business relationships between these doctors and their patients.

Appeal/Disposition: Defendants moved to dismiss the Second Amended Complaint, contending 1) that the doctors and professional organizations lack third-party and associational standing to assert these claims and 2) that Plaintiffs have failed to state a claim for breach of fiduciary duty under ERISA. Defendants’ Motion to Dismiss was granted as to Counts One through Three in the basis that Plaintiffs lack standing and have failed to state a claim and the Court declined to exercise supplemental jurisdiction over the remaining state law claims.

Violation Category: Reimbursement rates

Short Description: Plaintiffs–Appellants are two individual psychiatrists, Susan Savulak, M.D., and Theodore Zanker, M.D. (“the psychiatrists”), and three professional associations of psychiatrists, the American Psychiatric Association, the Connecticut Psychiatric Society, Inc., and the Connecticut Council of Child and Adolescent Psychiatry (collectively, “the associations”). They brought suit in the United States District Court for the District of Connecticut against Defendants–Appellees, four health-insurance companies: Anthem Health Plans, Inc., Anthem Insurance Companies, Inc., Wellpoint, Inc. and Wellpoint Companies, Inc. (collectively, “the health insurers”). The psychiatrists and the associations allege that the health insurers’ reimbursement practices discriminate against patients with mental health and substance use disorders in violation of the MHPAEA and ERISA. The associations brought suit on behalf of their members and their members’ patients, while the psychiatrists brought suit on behalf of themselves and their patients. The district court dismissed the case after concluding that the psychiatrists lacked a cause of action under the statute and the associations lacked constitutional standing to pursue their respective claims.

Appeal/Disposition: The appellate court affirmed the lower court’s decision.

Violation Category: N/A

Short Description: The Plaintiff is a coalition of managed behavioral healthcare organizations (MBHO) who contract with managed care organizations or with employers and states to manage behavioral care benefits. The Defendants are the Departments of Health and Human Services, Labor, and Treasury. The Plaintiffs argued that they will be irreparably harmed if the IFR are implemented, in that the IFR impose substantive regulations that the Plaintiff will have to comply with by a specified date.

Appeal/Disposition: The Court denied the Plaintiff’s Application for a TRO.

Violation Category: Residential Treatment

Short Description: Plaintiff suffered from addiction and on August 30, 2013, he was admitted to Malvern Institute, an inpatient, non-hospital addiction treatment facility, for detoxification. Plaintiff transferred to Malvern’s residential treatment program on September 5, 2013. His treatment in the residential treatment program was not authorized, and thus not paid for, by his health insurance carrier.  Before his transfer from the detoxification program to the residential treatment program, Plaintiff’s providers requested preauthorization from Independence Blue Cross’s (IBC) mental healthcare subcontractor, Magellan Behavioral Health (Magellan). Magellan denied the request. Plaintiff <span class="SS_CRBHighlight" data-id="I3BDYJGBF2X0008GT0S002MJ"><span class="SS_RFCPassage_Deactivated" data-func="LN.Advance.ContentView.getCitationMap" data-docid="5F46-S791-F04F-4013-00000-00" data-rfcid="I5F9P8K22HM6B60040000400">appealed to IBC and OPM simultaneously. OPM issued a final denial for treatment coverage, stating: </span></span>(1) the plan does not cover services billed by residential treatment facilities, and (2) Malvern is not a preferred provider.

Appeal/Disposition: Upon consideration of Plaintiff’s Complaint, Defendant’s Motion for a Protective Order Staying Discovery and to Quash Subpoena, Plaintiff’s responses thereto, and Defendant’s Motion to Dismiss or, in the Alternative, for Summary Judgment  Plaintiff’s response, Defendant’s reply, and Plaintiff’s sur-reply, Court denied Defendant’s Motion to Dismiss and granted Defendant’s Motion for Protective Order Staying Discovery to the extent that the Clerk of Court is directed to remand this matter to OPM to evaluate Smith’s claim for benefits in light of his contention that the Independence Blue Cross plan violates the law and to compile an administrative record related to its contract with Independence Blue Cross, including an explanation of its reasons for approving a plan that excludes residential treatment facilities.