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.