Health Reform WK-EDGE Complaint alleging violation of mental health parity requirements can proceed
Monday, July 1, 2019

Complaint alleging violation of mental health parity requirements can proceed

By Sheila Lynch-Afryl, J.D., M.A.

Members’ complaint sufficiently alleged that the insurer violated the Mental Health Parity Act by denying coverage for a wilderness and transitional care program.

Members of an employee benefits plan governed by the Employee Retirement Income Security Act of 1974 (ERISA) stated a claim for a violation of the Mental Health Parity Act for unequal coverage of mental health benefits. A private right of action under the Parity Act exists, and to suggest otherwise "is to ignore the Act’s very purpose." In addition, the complaint alleged a violation of the Act by describing comparable medical/surgical benefits that the plan does cover (Timothy D. v. Aetna Health and Life Insurance Co., No. 2:18-CV-753-DAK, June 14, 2019, Kimball, D.).

Members received benefits through their employer’s self-funded employee welfare benefit plan. The son of one of the members suffered from various mental health issues, which worsened in high school, and began experiencing substance abuse problems in college. After outpatient psychiatric therapy proved ineffective, he was enrolled first in Aspiro Wilderness Adventure Therapy and then in Dragonfly Transitions, a transitional living facility. Aetna Health and Life Insurance denied coverage for both facilities because the plan did not cover wilderness treatment facilities and Dragonfly did not meet the definition of a residential treatment facility.

The members filed a complaint against Aetna alleging, inter alia, a violation of the Mental Health Parity and Addiction Equity Act (29 U.S.C. §1185a(3)(a)) and the Patient Protection and Affordable Care Act (ACA) ACA (P.L. 111-148) for unequal coverage for mental health benefits. Aetna filed a motion for judgment on the pleadings, arguing that there is no private right of action and the Parity Act does not require coverage of wilderness treatment programs.

Aetna’s argument that there is no private cause of action under the Parity Act was in "direct contradiction with ERISA’s remedial framework." Furthermore, the members specifically alleged that Aetna’s exclusion of coverage for the type of care that their son received imposed a limitation on substance abuse and mental health benefits that was more restrictive than the limitations the plan imposed on medical/surgical benefits such as skilled nursing facilities, inpatient hospice care, and rehabilitation facilities. Aetna did not restrict coverage at these facilities based on medical necessity, geographic location, facility type, or provider specialty in the same way that it excluded coverage at Aspiro and Dragonfly.

The case is No. 2:18-CV-753-DAK.

Attorneys: Brian S. King (Brian S. King PC) for Timothy D. and Sue D. David N. Kelley (Fabian VanCott) for Aetna Health and Life Insurance and KPMG LLP Medical Benefits Plan.

Companies: Aetna Health and Life Insurance; KPMG LLP Medical Benefits Plan

Cases: CaseDecisions AccessNews AgencyNews EssentialBenefitNews GeneralNews InpatientFacilityNews InsurerNews UtahNews NewsFeed

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