Legal Cases: Unspecified Diagnosis - Page 2

Violation Category: Outpatient treatment

Short Description: Plaintiff engaged in outpatient psychotherapy sessions four times per week beginning in January 2011. In late February, CIGNA (Defendant’s contractor) sent a letter to Plaintiff’s physician stating that “should claims exceed 25 sessions, a case review based on medical necessity will be necessary.” CIGNA did not conduct a case review until June 7, 2011 at which time CIGNA determined that the treatment was not medically necessary. Plaintiff brought six counts alleging violations of MHPAEA. Defendant brought a Motion to Dismiss.

Appeal/Disposition: Defendant’s Motion to Dismiss was denied in part and granted in part.

Violation Category: The Plaintiff had a history of emotional and behavioral health issues and was receiving outpatient therapy. Her therapist recommended residential treatment when Plaintiff’s behavior became riskier. Plaintiff was enrolled in Second Nature Wilderness Program from June to August, 2006, and then placed in residential treatment at Island View from August 2006 to June 2007. Plaintiff’s insurance plan covered medically necessary inpatient hospital care, acute or subacute residential treatment, partial hospitalization, and intensive outpatient treatment for biologically-based mental conditions. Plaintiff’s claims for residential treatment were denied.

Short Description: Plaintiff appealed the denial of benefits through the Plan’s internal appeal process. The denial was upheld at each level of the appeal process by three different physicians. Plaintiff then sought external review of the decision through MAXIMUS, which upheld the denial. Defendant Blue Cross submitted Plaintiff’s claims for a second external independent review after receiving additional medical records. The second external appeal also upheld the denial of benefits as not medically necessary. The Court then considers whether the denial was arbitrary and capricious and found that the decision was not arbitrary and capricious and was supported by the medical opinion of five separate specialists. The Plaintiff argued that the observations and treatment recommendations from the Plaintiff’s treating specialists should be given more weight. The Court agrees that a diagnosis provided by a treating physician is more reliable, however, the process of reviewing a claim does not rely on the nuances of personal observation. As such, the decision to deny benefits is upheld.

Appeal/Disposition: The Defendant’s motion for summary judgment is granted. The Plaintiff’s motion for summary judgment is denied.

Violation Category: The Plaintiff was receiving in-network outpatient mental health visits. Her plan, a self-funded plan governed by ERISA, provided for an annual maximum of 30 visits and a lifetime maximum of 200 visits. Plaintiff’s treatment was covered until she exceeded the annual visit limitation.

Short Description: Plaintiff argues that the Parity Act prohibits the Plan from imposing limits on mental health coverage. The Defense argues that ERISA preempts the Parity Act from applying to the plan. The trial court granted Defendant’s motion to dismiss. In considering whether the Parity Act is preempted, the Court examines the express preemption clause in ERISA, and the subsequent savings clause. The Court finds that while the savings clause would preempt the Parity Act, the deemer clause, which exempts self-funded ERISA plans, ultimately governs. Thus, the deemer clause exempts the Plan from the Parity Act.

Appeal/Disposition: The Court upholds the trial court’s decision to dismiss.