United States District Court, D. Utah
E. M., T. M., and H. M., Plaintiffs,
HUMANA and NORTHSIDE HOSPITAL INC FLEXIBLE BENEFIT PLAN, Defendants.
MEMORANDUM DECISION AND ORDER GRANTING DEFENDANT
HUMANA’S MOTION TO DISMISS AND DENYING
PLAINTIFFS’ MOTION TO AMEND
CECILIA M. ROMERO MAGISTRATE JUDGE
matter is before the court on Defendant Humana’s Motion
to Dismiss Plaintiffs’ Second Cause of Action alleging
a violation of the Mental Health Parity and Addiction Equity
Act (Parity Act or MHPAEA) (ECF 16) and
Plaintiffs’ request for leave to amend their complaint
(ECF 22). On July 30, 2019, the court held a hearing
and took the matter under advisement. After considering the
parties’ briefing and oral argument, the court enters
the following Memorandum Decision and Order.
(E) and T.M. (T) are the parents of H.M. (H). E was a
participant in the Northside Hospital Inc. Flexible Benefit
Plan (Plan), and H was a beneficiary of the Plan. The Plan is
a self-funded employee welfare benefits plan under the
Employee Retirement Income Security Act of 1974 (ERISA). H
suffers from various mental health and behavioral issues and
has been diagnosed as being on the autism spectrum. H
received medical care and treatment at Daniels Academy
(Daniels), a residential treatment facility located in Utah.
Daniels provides sub-acute treatment to adolescents with
academic, behavioral, or social problems, including
individualized care for autism spectrum disorder. H stayed at
Daniels from December 29, 2015 through May 25, 2018.
submitted a claim to Humana for H’s treatment at
Daniels. Humana initially approved and paid for H’s
treatment at Daniels until January 12, 2016. Humana
thereafter denied payment for treatment because it determined
that H’s treatment did not meet the “medically
necessary” criteria. In a letter dated January 13,
2016, Humana provided the following justification for the
denial: “As of 1/12/16 your child has no acute symptoms
that require 24 hour nursing care. Your child is not a danger
to self or others. Your child is not aggressive. Your child
is medically stable. Residential treatment is denied 1/12/16-
forward. Your child can be treated in a lower level of care,
such as partial hospitalization.” Plaintiffs allege
that E incurred medical expenses totaling over $264, 000 that
should have been paid by the Plan.
bring two causes of action: (1) to recover benefits under the
Plan pursuant to section 1132(a)(1)(B) of ERISA; and (2) to
obtain equitable relief pursuant to section 1132(a)(3) of
ERISA for a violation of the Parity Act. Humana filed a
motion to dismiss the Second Cause of Action (ECF
16), arguing that the Parity Act claim is duplicative of
the denial of benefits claim, and that in any event,
Plaintiffs have failed to state a claim for a Parity Act
violation. Plaintiffs attached a proposed amended complaint
to their opposition to Humana’s motion to dismiss and
requested leave to amend their complaint (ECF 22).
Humana’s reply memorandum argued that the Second Cause
of Action is subject to dismissal under either complaint
Motion to Dismiss
Rule 12(b)(6) of the Federal Rules of Civil Procedure, a
court must dismiss a cause of action that “fail[s] to
state a claim upon which relief can be granted.”
Fed.R.Civ.P. 12(b)(6). In reviewing a motion to dismiss, the
court’s task is to “determine whether the
plaintiff has pleaded ‘enough facts to state a claim to
relief that is plausible on its face, ’ not just
‘conceivable.’” Warnick v. Cooley,
895 F.3d 746, 751 (10th Cir. 2018) (quoting Bell Atl.
Corp. v. Twombly, 550 U.S. 544, 570 (2007)). The
complaint “must give just enough factual detail to
provide ‘fair notice of what the ... claim is and the
grounds upon which it rests.’” Id.
(quoting Twombly, 550 U.S. at 555).
“‘Threadbare recitals of the elements of a cause
of action, supported by mere conclusory statements’ do
not count as well-pleaded facts.” Id. (quoting
Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009)).
“If, in the end, a plaintiff’s
‘well-pleaded facts do not permit the court to infer
more than the mere possibility of misconduct, ’ the
complaint fails to state a claim.” Id.
(quoting Iqbal, 556 U.S. at 679).
Motion to Amend
Rule 15(a) of the Federal Rules of Civil Procedure, a court
“should freely give leave when justice so
requires.” Fed.R.Civ.P. 15(a)(2). “‘A
proposed amendment is futile if the complaint, as amended,
would be subject to dismissal.’” Lind v.
Aetna Health, Inc., 466 F.3d 1195, 1199 (10th Cir. 2006)
(quoting Bradley v. J.E. Val-Mejias, 379 F.3d 892,
901 (10th Cir. 2004)). “In considering futility, the
Court employs the motion to dismiss standard and takes all
well-pled factual allegations as true.” Melissa P.
v. Aetna Life Ins. Co., No. 2:18-CV-216-RJS-EJF, 2018 WL
6788521, at *1 (D. Utah Dec. 26, 2018) (citing Ketchum v.
Cruz, 961 F.2d 916, 920 (10th Cir. 1992)).
Plaintiffs’ Second Cause of Action is subject to
dismissal because it fails to state a claim for which relief
can be granted under the Parity Act.
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.” Roy
C. v. Aetna Life Ins. Co., No. 2:17-CV-1216-DB, 2018 WL
4511972, at *3 (D. Utah Sept. 20, 2018) (citing ...