A suit was filed in Utah federal court by plaintiff Eric B., both individually and on behalf of his daughter, who is a minor. The defendants, Anthem Life and Health Insurance Company, Blue Cross of California, Anthem Um Services, the Intel Corporation Health and Welfare Plan, Intel, Inc. and a set of unknown individuals (collectively referred to as Anthem) are accused by the plaintiff of wrongfully denying his insurance claims in violation of both the Employee Retirement Income Security Act (ERISA) and the Mental Health Parity and Addiction Equity Act (MHPAEA).
The plaintiff’s daughter, referred to as “E” in the complaint, was born with a contracted aorta as well as a double inlet left ventricle. These congenital heart defects led to E requiring multiple open-heart surgeries. Complications from the surgeries led to extended hospital stays that included medically induced comas and required ventilator support.
E’s medical history has led to several struggles throughout her adolescence, according to the complaint, including ADHD, anxiety, and visual spatial processing disorder. A neuropsychological test revealed that E’s “cognitive function was borderline to impaired, her adaptive functioning was low average to borderline, and [she] had low average practical daily living skills, among other things.”
After experiencing all of E’s problems associated with her conditions, the plaintiff admitted her to a residential treatment facility called Elevations where she was to be treated for her “mental, emotional, and behavioral issues, developmental disturbances and environmental adjustment problems.”
Specialists at the facility described E to have generalized anxiety disorder, ADHD, and major neurocognitive disorder with behavioral disturbance. They noted that she had a high degree of potential for psychiatric hospitalization without residential treatment and needed “24/7 supervision in order to develop necessary skills and functional behavior.”
The plaintiff submitted claims for E’s treatment at Elevations under his insurance plan with Anthem Blue Cross. The plan is described in the complaint to be a self-funded employee welfare benefits plan under ERISA. The defendants promptly denied the claim, citing that the stay was not “medically necessary,” and that E did not require 24-hour care. The second denial letter from the defendants explained that this was Anthem’s final decision and that the plaintiff’s appeals were exhausted.
Before the plaintiff could request an external review of the decision, the defendants issued a new letter approving his claim in part. Approximately one-and-a-half months of E’s treatment was approved under the claim, with the remaining almost 3 months left uncovered. The plaintiff then submitted a request for an external review of the denial, arguing that E’s treatment was medically necessary under the definitions of the plan. Under the Mental Health parity and Addiction Equity Act of 2008, the plaintiff cited that the behavioral health benefits of the plan must be offered at parity with medical or surgical benefits. This request/appeal was once again denied by the defendants, who again cited a lack of medical necessity.
The complaint explains that the claim denials by the defendants constitute “a breach of contract and caused Eric to incur medical expenses that should have been paid by the Plan in an amount totaling over $50,000.”
The complaint cites violations of both ERISA and MHPAEA. The plaintiff is seeking favorable judgment on each count in the form of the total amount still owed for the treatment, litigation fees, and any other relief deemed proper by the Court.
The plaintiff is represented by Strong & Hanni.
