Health Reform WK-EDGE Parity determination requires discovery to detail claim adjudication process
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Friday, July 27, 2018

Parity determination requires discovery to detail claim adjudication process

By Patricia K. Ruiz, J.D.

The District of Massachusetts denied a motion to dismiss by Harvard Pilgrim Health Care Insurance Company (Harvard Pilgrim), finding that the process and factors by which a nonquantitative treatment limitation could be applied to both mental health benefits and medical/surgical benefits need to be evaluated after discovery to determine whether a violation of mental health parity requirements existed. The court, however, dismissed claims under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) where a private right of action was not permitted (Vorpahl v. Harvard Pilgrim Health Insurance Company, July 20, 2018, Casper, D.).

Denial of coverage. Harvard Pilgrim provided employer-sponsored health insurance to the members and three of their children, who were covered under their parents’ plan. The three children received treatment for mental health conditions at Red Cliff, an outdoor youth treatment program licensed by the state of Utah. Red Cliff, as a state-licensed program, must adhere to the same rules as residential treatment centers in Utah, including the requirement to perform an intake evaluation, create an individual treatment plan, create a discharge plan, and perform background checks of employees. The staffing requirements for the program required by Utah’s licensing board are "substantially similar" to those required for residential treatment centers.

Harvard Pilgrim denied coverage for the treatment and further denied the members’ appeal with a letter referencing language from the Harvard Pilgrim MA-PPO benefit handbook excluding health resorts, recreational programs, camps, wilderness programs, outdoor skills programs, relaxation or lifestyle programs and related services from coverage. The members brought suit on behalf of a putative class against Harvard Pilgrim under ERISA, arguing that the insurer denied benefits and breached its fiduciary duty to adjudicate benefits determinations in accordance with the Mental Health Parity and Addiction Equity Act (Parity Act) and the ACA. The members argued that (1) the text of the exclusion does not cover treatment provided by Red Cliff; (2) to the extent that the exclusion does cover treatment provided by Red Cliff, the exclusion violates the Parity Act; and (3) to the extent that the exclusion does cover treatment provided by Red Cliff, the exclusion violates the ACA. Harvard Pilgrim moved to dismiss the members’ claims.

Language of the exclusion. The members argued that the language of the exclusion is ambiguous and that the ambiguities must be construed against the insurer. They reasoned that the language is ambiguous because the other terms in the list are settings that do not provide any medical, surgical, or mental health services and that a reasonable beneficiary would not interpret the exclusion to extend to a licensed treatment provider. The court, however, found that the phrase "including any services provided in conjunction with, or as part of such types of programs" makes it clear that the exclusion includes services that might otherwise be covered when provided in the setting of a wilderness program.

Parity Act. The Parity Act provides that a group health plan that provides medical, surgical, and mental health or substance use disorder benefits must ensure that the treatment limitations applicable to the benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical/surgical benefits covered by the plan. The plan must ensure that there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits. In this case, the issue is whether the exclusion for wilderness programs applies equally to medical/surgical benefits and mental health or substance use disorder benefits.

Harvard Pilgrim argued that the appropriate comparison is not between mental health treatment in a wilderness therapy setting and medical/surgical treatment in a skilled nursing or rehabilitation hospital setting, but between whether coverage of both types of treatment would be excluded if offered in a wilderness program setting. The court found that this argument concerns the process and factors by which such a nonquantitative treatment limitation could be applied to both mental health benefits and medical/surgical benefits, which would need to be resolved after discovery. Thus, the court denied Harvard Pilgrim’s motion to dismiss the members’ Parity Act claims.

ACA. The members argue that the wilderness program exclusion violates the ACA provision prohibiting insurers from discriminating with respect to coverage against any health care provider acting within the scope of its license or certification under applicable state law (42 U.S.C. § 300gg-5). However, the court held that the provision does not prevent the application of exclusions from coverage and cannot be construed to require that an insurer provide coverage for any and all services that a provider might be licensed to provide. Further, the court cited precedent that the cited provision does not provide a private right of action, and there is no basis on which to consider this section of the ACA a provision of ERISA under which a private right of action exists. The court granted Harvard Pilgrim’s motion to dismiss as to the ACA claims.

The case is No. 1:17-cv-10844-DJC.

Attorneys: Deborah J. Winegard (Whatley Kallas, LLP) for Jacqueline Vorpahl. Damien C. Powell (Donoghue, Barrett & Singal, PC) for Harvard Pilgrim Health Care Insurance Co.

Companies: Harvard Pilgrim Health Care Insurance Co.

Cases: CaseDecisions AccessNews InsurerNews MassachusettsNews NewsFeed

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