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J.L. v. Anthem Blue Cross

United States District Court, D. Utah, Central Division

September 13, 2019

J.L., C.L., and A.L., Plaintiffs,
v.
ANTHEM BLUE CROSS and NORTHRUP GRUMMAN HEALTH PLAN, Defendants.

          MEMORANDUM DECISION & ORDER

          Dee Benson United States District Judge

         This matter is before the Court on Defendant Anthem Blue Cross's Motion for Judgment on the Pleadings and Partial Summary Judgment on Plaintiffs' Second Cause of Action (Dkt. 32), and Plaintiffs' Motion for Leave to File Amended Complaint (Dkt. 22). The motions have been fully briefed. The Court concludes that a hearing would not significantly aid its determination of the motions. Accordingly, the Court issues the following Memorandum Decision and Order based on the written submissions of the parties and the law and facts relevant to the pending motions. DUCivR 7-1(f).

         BACKGROUND

         This is an ERISA case.[1] J.L. and C.L. are the parents of A.L. (collectively “Plaintiffs”), all of whom are beneficiaries of a group health plan that is sponsored and funded by Defendant Northrup Grumman. (Dkt. 2, Compl. ¶¶ 1-2.) Defendant Anthem Blue Cross is the third-party claims administrator for the Plan. (Id. ¶ 3.)

         A.L. is a minor with a long history of mental health issues including but not limited to anxiety and depression. On May 13, 2016, A.L. was admitted to Sunrise, a residential treatment center for adolescent girls, located in Utah. A.L. was discharged from Sunrise on August 7, 2017. (Id. ¶¶ 23, 41.)

         A.L.'s first 50 days at Sunrise (May 13, 2016 through July 1, 2016) were covered by the Plan, based on Defendant's decision that the first 50 days were medically necessary. (Id. ¶ 33; Dkt. 31-1 Exh. C, May 20, 2016 Letter from Anthem (stating that A.L's initial10-day stay at Sunrise (from 05/13/16-05/23/16) was certified as “medically necessary”); Dkt. 31-1 Exh. D, Sept. 14, 2017 Letter from Anthem (approving 40 days of treatment at Sunrise stating: “It was determined that services from 5/23/16-07/01/16 were medically necessary”).) However, Defendant concluded that no benefits should be paid for A.L.'s stay at Sunrise after July 1, 2016, because Defendant determined it was not medically necessary under the terms of the Plan and applicable residential treatment center criteria. (Dkt. 2, Compl., ¶ 39; Dkt. 31-1 Exh. D.)

         Plaintiffs appealed the denial of coverage and exhausted the administrative appeals process. (Id. ¶ 42.)

         On August 28, 2018, Plaintiffs filed the Complaint in this case, seeking to recover benefits for A.L.'s stay at Sunrise from July 2, 2016 through August 7, 2017. Plaintiffs' Complaint sets forth two causes of action: (1) a claim for benefits pursuant to ERISA under 29 U.S.C. 1132(a)(1)(B); and (2) a claim alleging violation of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) under 29 U.S.C. § 1185a(a)(3)(A)(ii).

         Both parties have motions pending before the Court. Defendant seeks summary judgment on Plaintiffs' Second Cause of Action - the MHPAEA claim. (Dkt. 32.) Plaintiffs seek leave to file an Amended Complaint. (Dkt. 22.)[2]

         DISCUSSION

         1. Defendant's Motion for Summary Judgment on Plaintiffs' Second Cause of Action Alleging Violation of the Mental Health Parity and Addiction Equality Act

         Defendant asks this Court to grant summary judgment on Plaintiffs' Second Cause of Action which is based on the Mental Health Parity and Addiction Equality Act. The MHPAEA “prohibits the imposition of more stringent treatment limitations for mental health treatment than for medical treatment.” Bushnell v. UnitedHealth Group, Inc., 2018 WL 1578167, *4 (S.D.N.Y. Mar. 27, 2018). The Act requires that if a health plan provides “both medical and surgical benefits and mental health or substance abuse disorder benefits, ” then the plan must ensure that (1) “the treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage)”; and (2) “there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits.” 29 U.S.C. § 1185a(a)(3)(A)(ii).

         Treatment limitations under the MHPAEA can be quantitative or nonquantitative. 29 C.F.R. § 2590.7212(a). Quantitative limitations include, for example, a limitation on the number of outpatient visits that an insurance plan will cover. Id. Nonquantitative limitations include “restrictions based on geographic locations, facility type, provider specialty, and other criteria that limit the scope ...


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