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.