United States District Court, D. Utah, Central Division
KERRY W. and N.W., Plaintiffs,
ANTHEM BLUE CROSS AND BLUE SHIELD, Defendant.
MEMORANDUM DECISION AND ORDER GRANTING
DEFENDANT'S MOTION TO DISMISS PLAINTIFFS' SECOND
CAUSE OF ACTION
Benson United States District Judge.
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
following facts are taken from Plaintiffs' Complaint and
are viewed in the light most favorable to Plaintiffs as the
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.
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.)
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
Kerry filed the permissible pre-litigation appeals regarding
Anthem's denial of N.W.'s treatment. 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.)
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.)
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.)
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
TO DISMISS STANDARD
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,
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.
HEALTH PARITY AND ...