After appealing two separate denials of coverage for treatment at facilities specializing in “mental health, behavioral, and/or substance abuse problems” in adolescents, an aggrieved parent has filed suit in the District of Utah against the insurer and plan, Cigna Health and Life Insurance Company (Cigna) and the Vermont Electric Power Company Healthcare Benefit Plan (the plan). Yesterday’s civil action contends that Cigna unfairly denied the minor’s claim in violation of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
The complaint claims that the plan, covered by the Employee Retirement Income Security Act of 1974 (ERISA), must reimburse the plaintiff for costs incurred and paid for in connection with the minor’s care. It explains that beginning in 2018, the minor enrolled at the treatment facility Red Cliff Ascent (RCA) “due to a significant history of substance use issues coupled with multiple mental health diagnoses.”
After the RCA claim was submitted, Cigna denied coverage finding that the facility did not qualify as a “mental health (psychiatric) residential treatment program,” but was rather an “outdoor youth program.” On appeal, and in January 2019, Cigna again denied the claim on the same basis, finding in part that “covered benefits do not include coverage for wilderness programs.”
In April 2018, the minor enrolled at another residential care facility, Telos. This time, Cigna denied the claim because the treatment was deemed not medically necessary. On appeal, the insurer held fast.
In his lawsuit, the plaintiff argues that Cigna, among other things, improperly denied coverage based on RCA’s geographic location or provider specialty. In addition, Cigna’s analysis of medical necessity was unduly stringent, and failed to consider the severity of the patient’s condition as to care rendered at Telos, according to the plaintiff. The method of evaluation therefore deviated from “generally accepted standards of medical practice,” and in turn violated the law, the plaintiff contends.
The filing asks for reimbursement of the allegedly wrongfully withheld coverage, pre and post-judgment interest, equitable relief, and an award of the plaintiff’s attorneys’ fees and costs. Notably, in another case filed by the same counsel, Brian S. King, P.C., on the same day, that plaintiff similarly challenged the denial of a claim concerning her minor son’s treatment at a Missouri mental health residential care facility.
