A suit was filed in the District of Utah last Thursday by plaintiff David F. and his minor child against defendant Anthem Blue Cross (Anthem). In the complaint, the plaintiffs alleged that their insurance provider, the defendant, had improperly denied an insurance claim they had filed on behalf of the plaintiff’s mental heal treatments throughout 2019 and 2020.
Plaintiff David F. and his child, D.F., are under an insurance plan administered by the defendant. The plan is described in the action as a fully insured employee welfare benefits plan under the Employee Retirement Income Security Act of 1974 (ERISA).
Throughout 2019 and 2020, D.F. received different treatments at Elements Wilderness Program and Catalyst Residential Treatment. Both facilities are licensed treatment centers that “provide sub-acute inpatient treatment to adolescents with mental health, behavioral, and/or substance abuse problems.”
When the plaintiff submitted a claim for the respective treatments, Anthem denied the claim on the basis that the Elements Wilderness was not covered under the plan, while Catalyst Residential Treatment was denied on the basis that the treatment was not deemed medically necessary.
The plaintiff countered both denials by reminding the defendant of its ERISA obligations and that the defendant’s denial violated MHPAEA, which rules that mental health benefits must be offered at parity with similar medical or surgical services. He reasoned that the plan’s exclusion for wilderness camps did not apply to the Elements Wilderness Program because the exclusion did not apply to individuals who were suffering from “serious emotional disturbances of a child,” and that the Catalyst Residential Treatment was medically necessary as David F.’s son might have otherwise “ended up dead due to his substance use, mental health conditions, and suicidal ideation.”
David F.’s appeal was later denied by Anthem, who explained that D.F. “was not at risk for serious harm from withdrawals that you needed 24 hour care.” Anthem also stated that they treat residential treatments the same as other levels of care, and therefore they did not violate MHPAEA as the plaintiffs argued. After Anthem upheld their denial, plaintiff David F. concluded that he had exhausted all of his pre-litigation appeal obligations.
The complaint cites a claim for recovery of benefits and a violation of the MHPAEA. The plaintiffs are seeking favorable judgment on each count, the total amount owed for D.F.’s medically necessary treatment, appropriate equitable relief, litigation fees, and any other relief deemed just by the Court.
The plaintiff is represented by Brian S. King.
