Pension & Benefits News Failure to allege facts dooms claim that insurance company violated Parity Act
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Friday, March 6, 2020

Failure to allege facts dooms claim that insurance company violated Parity Act

By Pension and Benefits Editorial Staff

Although a participant in a medical plan and her son alleged that he was a beneficiary under the plan and that mental health or substance abuse benefits were more restrictive than limitations for medical and surgical benefits, the claim alleging violations of the Parity Act was dismissed because the plaintiffs’ claims were simply "conclusory and formulaic recitations of the law," that failed to allege facts with specificity.

Care. One of the plaintiffs was a participant in a medical plan administered by the insurance company. Her son was a beneficiary of the plan. Once the son started middle school, he exhibited "troubling behavior," including substance abuse, selling drugs, stealing and lying. He was diagnosed with attention deficit disorder, oppositional defiance disorder, and features of narcissistic personality disorder.

Coverage. In light of his illnesses, he was admitted to a residential treatment program, where he spent about four months. However, the insurance company denied coverage for treatment provided after about the first month, asserting that the son did not met the plan’s guidelines for additional coverage in a residential treatment facility. The parents and son appealed several times, but the insurance company held its ground.

Thereafter, the family filed a two-count complaint, one of which was a claim that the insurance company violated the Parity Act. The insurance company filed a motion to dismiss the Parity Act claim, as well as two individual claims.

Parity. In reviewing the motion to dismiss, the court explained that the Parity Act "requires that a plan’s treatment and financial limitations on mental health or substance abuse disorder benefits cannot be more restrictive than the limitations for medical and surgical benefits," the court said, citing a case that set out the statutory language. Specifically, a Parity Act claim must consider limitations on mental health or substance abuse claims in comparison to medical or surgical treatment benefits. In order to survive a motion to dismiss, plaintiffs must plead facts that support the allegation that the plan treats coverage for mental health or substance abuse differently than that provided for medical or surgical treatments.

In this instance, the family asserted that the insurance company violated the Parity Act because it required that the son satisfy acute care medical necessity criteria for treatment in a sub-acute residential treatment facility, when there are no such requirements for individuals seeking medical or surgical sub-acute plan benefits.

Specifically, the family alleged that the terms of the plan’s medical necessity requirements limited coverage for mental health and substance abuse disorder treatment in a manner that is inconsistent with and more stringently applied to "the processes, strategies, standards or other factors used to limit coverage for medical/surgical treatment in the same classification," the court noted, citing the complaint.

In its analysis, the court found that the family’s pleadings failed to include allegations sufficient to sustain a claim under the Parity Act. Although the complaint included assertions that there was disparate treatment, there was not factual support for the allegations, according to the court. The court found that the Parity Act claim was not supported by well-pleaded facts, but rather, only by speculative statements, legal conclusions and simple recital of relevant statutory language.

The court rejected the family’s argument that they were "handicapped" by the insurance company’s failure to provide them with medical necessity criteria both for mental health and substance abuse and for skilled nursing and rehabilitation facilities. The court acknowledged that under the Parity Act’s final rules, claimants are entitled to certain documentation relevant to their claim for benefits, but pointed out that in this instance, the insurance company had informed the family where they could find those resources.

Specifically, the court noted that the letters denying coverage for the son’s stay at the rehabilitation center advised the family where online they could access relevant plan documents that included an explanation of the criteria for treatment benefits for both medical and surgical treatment and mental health and substance use disorder treatment. Thus, the family had reasonable access to the medical necessity criteria, and as a result, their conclusory and speculative claim was insufficient to withstand the insurance company’s motion to dismiss.

SOURCE: Laurel R. v. United Healthcare Insurance Co., (D. Utah) No. 2:19-cv-00473-DB, February 5, 2020.

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