Blue Cross of California Sued Over Wilderness Program Coverage

On Thursday a case was filed in the Northern District of California against Blue Cross of California. The case alleges breach of ERISA fiduciary duties for failure to pay for mental health claims.

The Federal Mental Health Parity and Addiction Equity ACT (MHPAEA) and the California equivalent both require that health plans provide mentally necessary care and treatment for specified mental health illness to a level equivalent to that provided for medical treatment. California Senate Bill 855 goes further and prohibits certain types of limitations on mental health coverage and also requires that health plans not use a proprietary internal guidelines for determining the necessity of mental health treatment and instead use third party non profit guidelines that provide greater transparency for review and appeal.

The plaintiff’s daughter was a covered insured with an ERISA health insurance plan administered by Blue Cross of California. The patient had a long history of depression with suicidal ideation and had no relief with basic therapy or medication. The patient was admitted to Newport Academy Redwood, where she found some relief, but after discharge her condition deteriorated again. After a brief inpatient hospitalization she was admitted to Open Sky Wilderness program, where she again found some relief. Blue Cross has denied the claims from both Newport and Open Sky. During both hospitalizations, the medical providers treating the patient indicated that the treatment was medically necessary.

The plaintiff is suing for recovery of benefits and breach of fiduciary duty. The plaintiff is represented by the DL Law Group.