Defendants Including Premera Blue Cross Sued Over Health Coverage Denial

A suit was filed on Friday in the District of Utah by plaintiff J.J. (individually and on behalf of G.J., a minor) against defendants Premera Blue Cross, Services, Inc., and the Amazon and Subsidiaries Shared Deductible Plan. The complaint accuses the defendants of improperly refusing coverage to the plaintiff under her healthcare plan.

The defendants were the agents and administrators of the plaintiff’s healthcare plan, which was a “self-funded employee welfare benefits plan.” The plaintiff’s minor child, G.J., was a beneficiary under the plan, the complaint said.

The complaint explained that, in 2019 and 2020, G.J. received medical care and treatment at Trails Carolina and Maple Lake Academy. The care extended beyond early 2020, but the defendants were no longer responsible for the treatment following that point because the plaintiff switched employers.G.J. received treatment at the aforementioned facilities due to issues with “depression, anxiety, suicidal ideation, property destruction, trauma, and significant aggression which had not been able to be adequately managed at other levels of care.”

Defendant Premera denied coverage to the plaintiff for transportation to Trails Carolina, citing that medical treatment requiring travel was not a benefit covered under the plan. Though Premera did not explicitly deny coverage of the treatment itself, the plaintiff explains that she presumed they had denied such coverage based on their communications. The defendants also denied coverage at Maple Lake Academy, claiming that it was not medically necessary.

Plaintiff J.J. reasoned that Trails Carolina met the plan’s definition of a provider, and that Maple Lake Academy also met the requirements for coverage to be approved. This, in combination with the facilities’ licensure, accreditation, and compliance with governing state regulations led the plaintiff to argue that the treatment should have been covered under the plan.

The outstanding coverage, J.J. asserts, is a violation of the Mental Health Parity and Addiction Equity Act (MHPAEA), which ensures that mental health benefits are offered at parity with medical and surgical benefits. J.J. alleges that the defendant’s actions made it evident that they are “restricting the availability of mental healthcare in a manner which it did not do with analogous medical or surgical services and that it appeared to be limiting the availability of wilderness care merely because it took place outdoors.”

Even when the plaintiff asked the defendant to conduct a parity compliance analysis and asserted her entitlement to relief concerning Trails Carolina, the defendants did not respond to her. Premera continually upheld their denial of the Maple Lake Academy treatment. Following lengthy communication pertaining to the coverage, the plaintiff deemed that her pre-litigation appeal obligations had been exhausted and filed suit.

The complaint cites a claim for recovery of benefits, a violation of MHPAEA, and a request for statutory penalties. Plaintiff J.J. is seeking favorable judgment on each count, equitable relief, statutory penalties, litigation fees, and any other relief deemed proper by the Court.

The plaintiff is represented by Brian S. King.