On Thursday a case was filed in the District Court of Utah by an ERISA-regulated insured on behalf of their minor child against CIGNA Health and Life Insurance Company as third party administrator and INTEL Corporation ERISA Benefits Plan. The complaint is regarding the processing of mental health related claims and failure to properly process and pay the claims per ERISA and the Mental Health Parity and Substance Abuse Act (MHPAEA).
The plaintiff’s child, according to the complaint, was suffering from several conditions, including violent and paranoid behaviors, ADHD, and other conditions. The patient received various local treatments and interventions, including a behavior contract enforced through the court system after a criminal encounter with the police.
These interventions, court documents say, did not resolve the issues and the plaintiff sought higher level treatment through the SUWS residential outdoor therapy program and the Dragonfly outdoor therapy program. After billing these services to the defendant insurance plan, Cigna as third party administrator denied the benefits as non-covered.
The plaintiff appealed these denials internally with Cigna, indicating that Cigna was holding the mental health treatment to a higher standard than medical treatment which is not permissible under the MHPAEA, as well as denying the treatment simply based on the name of the treatment and not on its medical necessity. Cigna denied and the plaintiff now seeks court review.