Health Reform WK-EDGE Moms get another chance at class certification in seeking lactation service reimbursement
Wednesday, July 17, 2019

Moms get another chance at class certification in seeking lactation service reimbursement

By Cathleen Calhoun, J.D.

A health care provider’s approach to compliance with the ACA was "haphazard"—sometimes reimbursing for lactation services, sometimes not—making class action certification difficult for plaintiffs, for now.

A motion for class certification, brought by six women who alleged that a health care company failed to provide coverage for certain health care services, was denied without prejudice. The women claimed that the health care company failed to provide coverage for lactation services as required by the Affordable Care Act (ACA) (P.L. 111-148). Specifically, the health care company allegedly did not reimburse them for out-of-network lactation services after they could not obtain those services in-network. According to the court, many problems existed with the class certification, including lack of evidence and a possibly overbroad class. However, the court said that given the complexity of the evidence presented, as well as the significant possibility that certification for a class of people could be achieved, it would exercise its discretion and grant another chance at class certification (Condry v. UnitedHealth Group Inc., May 23, 2019, Chhabria, V.).

Classes. The plaintiffs sought two classes: (1) a class of ERISA plan participants who were denied coverage for lactation services; and (2) a class of non-ERISA plan participants who were denied that coverage. Three of the remaining named plaintiffs had ERISA plans and one had a non-ERISA plan.

Problems. The court cited numerous problems with creating a class within the group of plaintiffs. Specifically, the court found the following problems:

  1. The proposed classes consist of all people denied lactation coverage, whether in-network or out-of-network. According to the court, the ACA is violated only for failure to reimburse for out-of-network services when those services are not available in-network.
  2. The plaintiffs did not present adequate evidence that liability could be determined (or that any significant issues could be resolved) on a class-wide basis.
  3. The named plaintiffs did not appear to have standing to seek prospective relief because they are no longer plan participants.
  4. Even if the named plaintiffs had standing to seek an order that would remedy past violation, it is not clear what remedy they seek.

Conclusion. In reaching its conclusion, the court acknowledged the complexity of the evidence. Despite finding numerous problems with class certification, the court reasoned that the plaintiffs could probably at least obtain certification for a class of people who did not receive adequate denial explanations. As a result, the court exercised its discretion to grant the plaintiffs leave to take another shot at class certification.

The case is No. 17-cv-00183-VC.

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