Priority Health Sued Over Non-Covered Wilderness Treatment

On Tuesday a case was filed in the District of Utah by a patient on behalf of his minor child as ERISA health plan beneficiaries against Priority Health Managed Benefits and The Michigan Dental Association Health Plan. The case is regarding the improper denial of benefits for mental health treatment under the ERISA and Mental Health Parity and Addiction Equity Act (MHPAEA).

The MHPAEA requires that plans governed by the ERISA Act not impose more restrictive standards for treatment of mental health or substance abuse treatments than those that are imposed upon medical treatments.

The patient was diagnosed with a large number of mental health issues, according to the plaintiff, including depression, attachment disorder, anxiety, ADHD, and other related conditions and also expressed self harming behaviors and addictions. The patient had previously received lower level treatments including outpatient psychiatric sessions, however they were insufficient to stabilize or improve the symptoms.

After a major panic issue, the plaintiffs sought a higher level inpatient treatment, beginning with Evoke wilderness treatment and later with Vista inpatient treatment. The defendants denied the treatment with Evoke, stating that the plan categorically did not cover wilderness treatment settings and considered them not medically necessary. The plan also denied treatment at Vista, indicating that it was a luxury treatment setting.

The plaintiff said they pursued internal appeals, noting that the patients condition warranted inpatient treatment, noting that there was no specific prohibition for this type of treatment in the plan documents, and also noting that there was documented improvement in the patients condition. All internal appeals were denied without further provision of information.

The plaintiff is suing for recovery of benefits and violation of the MHPAEA. They are represented by the Law Firm of Brian S. King. No counsel has been entered for the defendant to date.