L.L. v. Anthem Blue Cross Life and Well being Ins., 2023 WL 2480053 (D. Utah 2023)

A bunch well being plan participant sued the plan, its claims administrator, and her employer (as plan administrator) after the plan denied protection for wilderness remedy for her daughter’s psychological well being points and substance use dysfunction. The denial letter said that the remedy was excluded underneath the plan as investigational and never medically needed as a result of there was not sufficient proof that wilderness remedy improves well being outcomes. After a number of ranges of exterior evaluation, the participant sued underneath the Psychological Well being Parity and Habit Fairness Act (MHPAEA), arguing that the plan impermissibly excluded wilderness applications for psychological well being/substance use dysfunction (MH/SUD) advantages however not for analogous medical/surgical advantages. She additionally sought statutory penalties underneath ERISA for the claims administrator’s failure to supply requested plan paperwork. The employer and claims administrator asserted that the exclusion utilized equally to all wilderness applications, whether or not supposed to deal with medical circumstances or behavioral well being problems. And so they sought dismissal of the declare for statutory penalties, arguing that solely the designated plan administrator (right here, the employer) will be held answerable for statutory penalties, and the participant didn’t allege that she had requested paperwork from the employer.

Noting {that a} profitable MHPAEA declare requires a participant to plead information displaying a disparity within the plan’s remedy of MH/SUD and medical/surgical advantages, the courtroom concluded that the participant’s allegation was unsupported and contradicted plan language expressly making use of the exclusion to each varieties of advantages. The courtroom additionally dismissed the declare for statutory penalties, holding that neither the claims administrator nor the employer may very well be held liable the place the participant made the doc request to the claims administrator slightly than to the employer because the designated plan administrator. A separate declare for restoration of advantages underneath ERISA (based mostly on the participant’s arguments and proof that wilderness applications will not be investigational) was not contested and was allowed to proceed.

EBIA Remark: Wilderness remedy exclusions are a frequent goal of litigation, with courts reaching totally different conclusions based mostly on particular allegations (see, e.g., our Checkpoint article). Plan sponsors, directors, and their advisors ought to pay explicit consideration to such exclusions, guaranteeing that they don’t run afoul of the MHPAEA. As well as, exclusions of this kind are thought-about nonquantitative remedy limitations (NQTLs) that should be addressed in a plan’s required NQTL comparative analyses (see our Checkpoint Query of the Week). For extra data, see EBIA’s Group Well being Plan Mandates guide at Sections IX.E (“Nonquantitative Therapy Limitations”) and IX.Ok (“Psychological Well being Parity: Desk of Circumstances”). See additionally EBIA’s Self-Insured Well being Plans guide at Part XIII.C.2 (“MHPA and MHPAEA: Psychological Well being Parity”).

Contributing Editors: EBIA Workers.