Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Kerry W. v. Anthem Blue Cross and Blue Shield

United States District Court, D. Utah, Central Division

June 5, 2019

KERRY W. and N.W., Plaintiffs,
v.
ANTHEM BLUE CROSS AND BLUE SHIELD, Defendant.

          MEMORANDUM DECISION AND ORDER GRANTING DEFENDANT'S MOTION TO DISMISS PLAINTIFFS' SECOND CAUSE OF ACTION

          Dee Benson United States District Judge.

         This matter is before the Court on Defendant's Motion to Dismiss Plaintiffs' Second Cause of Action, alleging a violation of the Mental Health Parity and Addiction Equality Act, pursuant to Rule 12(b)(6) of the Federal Rules of Civil Procedure.

         FACTUAL BACKGROUND

         The following facts are taken from Plaintiffs' Complaint and are viewed in the light most favorable to Plaintiffs as the non-moving party.

         Kerry W. is the mother of N.W. Both Kerry W. and N.W. were beneficiaries of a group health plan insured by Anthem. (Compl. ¶¶ 1, 3.) For many years N.W. has struggled with mental heath issues and substance abuse. (Id. ¶¶ 9-24.)

         Elevations Residential Treatment Center is a licenced facility that provides sub-acute inpatient treatment to adolescents with mental health, behavioral, and substance abuse problems. (Id. ¶ 4.) N.W. was admitted to Elevations on September 14, 2015 through August 25, 2016, and then again on October 5, 2016 through January 23, 2017. (Id.)

         Anthem initially approved and paid for the first 4½ months of N.W.'s treatment at Elevations. However, Anthem denied payment for treatment after February 1, 2016, because Anthem determined that N.W. did not meet the “medically necessary” criteria. (Compl. ¶ 26.) In a letter dated February 5, 2016, Anthem provided the following justification for the denial: “The information we have shows you are no longer harming yourself, you are able to control your behavior and you no longer need 24 hour structured care. For this reason, the request for you to remain in residential treatment is denied as not medically necessary.” (Id.)

         Thereafter, Kerry filed the permissible pre-litigation appeals regarding Anthem's denial of N.W.'s treatment.[1] Kerry provided letters and medical records in support of her position that N.W. met the medical necessity criteria for continued residential treatment, and Kerry argued, among other things, that: (1)Anthem acted improperly in considering only N.W.'s mental health issues given that N.W. had a “dual diagnosis” of mental health disorders and substance abuse issues; (2) N.W. met the plan's definition for “medical necessity”; and (3) Anthem's denial letters did not sufficiently explain Anthem's rationale because the letters failed to address N.W.'s dual diagnosis and failed to counter the medical records she provided. (Id. ¶¶ 27-47.) Kerry also requested that Anthem provide her with a copy of all governing plan documents, including the mental health criteria and the skilled nursing and rehabilitation facility criteria. (Id. ¶ 46.)

         Throughout the appeals process, Anthem maintained and upheld the denial of N.W.'s treatment on the same grounds. (Id. ¶ 48.) Additionally, Anthem failed to provide Kerry with the requested plan documents. (Id. ¶ 49.)

         Having exhausted the pre-litigation appeal obligations under the Plan and ERISA, Plaintiffs filed the Complaint in this case, setting forth two causes of action. In the First Cause of Action, Plaintiffs assert a “Claim for Recovery of Benefits, ” pursuant to ERISA, 29 U.S.C. § 1132(a)(1)(B), for the days that Anthem did not cover N.W.'s treatment at Elevations. Plaintiffs' Second Cause of Action asserts a Claim for Violation of the Mental Health Parity and Addiction Equity Act, pursuant to 29 U.S.C. § 1185a(a)(3)(A)(ii), 29 U.S.C. § 1132(a)(3), asserting generally that the Plain provides less generous coverage for treatment of mental health and substance abuse disorders than it provides for the treatment of medical and surgical disorders. (Compl. at pp. 13-14.)

         In the motion now before the Court, Defendant moves to dismiss Plaintiffs' Second Cause of Action - the MHPAEA claim - pursuant to Rule 12(b)(6) of the Federal Rules of Civil Procedure.

         MOTION TO DISMISS STANDARD

         In considering a motion to dismiss pursuant to Rule 12(b)(6), all well-pleaded factual allegations, as distinguished from conclusory allegations, are accepted as true and viewed in the light most favorable to Plaintiffs as the non-moving party. GFF Corp. v. Associated Wholesale Grocers, Inc., 130 F.3d 1381, 1384 (10th Cir. 1997). Plaintiff must provide “enough facts to state a claim to relief that is plausible on its face.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007). This requires “more than an unadorned, the-defendant-unlawfully-harmed-me accusation.” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009). “A pleading that offers ‘labels and conclusions' or a ‘formulaic recitation of the elements of a cause of action will not do.' Nor does a complaint suffice if it tenders ‘naked assertion[s]' devoid of ‘further factual enhancement.'” Id. (quoting Twombly, 550 U.S. at 557) (alteration in original). Accordingly, this Court's role “is not to weigh potential evidence that the parties might present at trial, but to assess whether the plaintiff's complaint alone is legally sufficient.” Miller v. Glanz, 948 F.2d 1526, 1565 (10th Cir. 1991). “[W]here the well-pleaded facts do not permit the court to infer more than the mere possibility of misconduct, the complaint has alleged - but it has not shown - that the pleader is entitled to relief.” Iqbal, 556 U.S. at 679.

         MENTAL HEALTH PARITY AND ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.