On Friday in the District of Utah, Judge Ted Stewart denied United Behavioral Health (UBH) and Motion Picture Industry Health Plan for Active Participants’ motion to dismiss a claim by individual plaintiffs that alleged that the defendants violated the Mental Health Parity and Addiction Equity Act of 2008 (Parity Act) through coverage denial.
The plaintiffs, a parent and a dependent, stated that UBH denied coverage of the dependent’s residential therapy treatment at Evoke Wilderness Program. The company claimed such programs are “experimental and unproven” and that the dependent was “not at risk,” of self-harm or harm to others, “was medically stable, was not experiencing withdrawal symptoms, was not under the care of a psychiatrist, and did not require 24-hour medical or psychiatric care,” the court explained. After the wilderness program, the dependent was admitted to Catalyst Residential Treatment, which the plaintiffs claimed was covered by UBH for about a month — from April 28, 2017, through May 26, 2017 — but then was denied until the dependent left on July 31, 2018. The plaintiffs submitted appeals that failed, and they ultimately resorted to filing a complaint alleging violations of the Employee Retirement income Security Act (ERISA) and the Parity Act. The defendants moved to dismiss the Parity Act cause of action for failure to state a claim, which the judge denies for the following reasons.
The defendants argued that in order to properly allege a Parity Act violation, the plaintiffs must “(1) identify a specific treatment limitation in (the) plan applicable to behavioral health treatment; (2) identify services in the medical or surgical arena that are both covered under the plan and analogous to the specific behavioral health services at issue; and (3) plausibly allege a disparity in the limitation criteria applicable to this analogous medical or surgical service on the one hand and the mental health or substance use treatment on the other,” pursuant to Welp v. Cigna Health and Life Insurance Company. The judge amended the third criterion to reflect that “the disparities in treatment limitations may be found in the language of the plan or in application of the plan,” thus requiring that the plaintiffs “plausibly allege a disparity between the treatment limitation on mental health/substance abuse benefits as compared to the limitations that (Defendants) would apply to the covered medical/surgical analog.”
With the court’s standards set forth, the judge found that the plaintiffs do properly allege all of the elements to satisfy the stating of a claim. On the first element, the plaintiffs noted “acute medical necessity criteria” that the dependent did not satisfy according to UBH, including being “medically stable” and not at risk of self-harm; the judge finds this iteration reflective of the “specific treatment limitation” requirement. Secondly, the judge found that the plaintiffs’ identification of care received at places such as “skilled nursing facilities, inpatient hospice care, and rehabilitation facilities” to pass as analogous to the dependent’s care received at Evoke and Catalyst, citing that this court in the past has determined that it is sufficient to compare residential and wilderness treatment programs for mental health to inpatient hospice and rehabilitation facilities. Lastly, although the defendants argued that the plaintiffs would need to be more specific regarding any alleged disparity between limitations applied to mental health treatment benefits and medical/surgical treatment benefits, the judge stated that “(m)ore detailed information about the criteria for the medical/surgical analogues is not currently in Plaintiffs’ possession” and, thus, what the plaintiffs argued was sufficient enough to state a claim.