Archives for November 18, 2014

The Federal Mental Health Parity and Addiction Equity Act (“MH Parity Act”) requires, at a minimum, that the financial requirements and treatment limitations for mental health benefits set by group health plans and health insurance carriers be no more restrictive than those provided for non-mental health medical benefits.  The MH Parity Act was originally signed into law by President Bill Clinton in 1996 and amended the Employee Retirement Income Security Act (ERISA) and Public Health Service Act and Internal Revenue Code in 2008.  Now, the MH Parity Act is at issue in an increasing number of cases and has been addressed several times by the federal courts in the Ninth Circuit Court of Appeals.

Daniel F. v. Blue Shield of California, U.S. Dist. LEXIS 111643 (N.D. Cal. Aug. 11, 2014) began with two parents seeking coverage for residential treatment of their minor son’s mental health condition under their Blue Shield health insurance plan, governed by ERISA.  Blue Shield denied the claim, stating its policy excluded coverage of residential treatment services for severe mental health conditions.  Plaintiffs brought suit alleging violation of the insurance contract and a claim for declaratory and injunctive relief, but the court granted summary judgment for Blue Shield.  During the appeal of this case, the Ninth Circuit issued Harlick v. Blue Shield of California, 686 F.3d 699 (9th Cir. 2012) holding the MH Parity Act requires health plans to provide coverage for all medically necessary treatment for severe mental illness, subject to the same financial terms as imposed on coverage for physical illnesses.  Plaintiffs sought to maintain a class action against Blue Shield on behalf of participants covered under Blue Shield health insurance plans, governed by ERISA, whose claims for residential treatment of mental health claims were denied.  However, the court explained class certification would require individualized discovery and proof, inquiries into medical necessity and whether individual mental health conditions and treatment were covered under the California Parity Act and additional difficulties with determining damages.  Ultimately, the court held Plaintiffs failed to articulate a definition of an ascertainable class, and denied the motion for class certification.

Brazil v. OPM, 2014 U.S. Dist. LEXIS 44856 (N.D. Cal. Mar. 28, 2014) involved a plaintiff who received medically necessary mental health treatment at a residential facility, but her federal health insurance plan excluded coverage for residential treatment.  The Plaintiff exhausted all administrative remedies and brought suit against the Office of Personnel Management (“OPM”) in federal court.  The court held the plaintiff cannot recover under the MH Parity Act because the OPM has sovereign immunity, and Congress did not consent to be sued under the MH Parity Act.  Brazil demonstrates the MH Parity Act did not apply to federal insurance plans.

A.F. v. Providence Health Plan, 2014 U.S. Dist. LEXIS 109507 (D. Or. Aug. 8, 2014) involved plaintiffs who sought an order enjoining the insurer, Providence Health Plan, from excluding applied behavior analysis therapy for participants diagnosed with autism spectrum disorders.  The court granted the plaintiffs’ partial motion for summary judgment holding Providence’s “Developmental Disability Exclusion,” which excluded coverage for services relating to “developmental disabilities, developmental delays or learning disabilities” but not medical or surgical conditions, constituted a violation of the MH Parity Act and the Oregon Mental Health Parity Act.

R.H. v. Premera Blue Cross, 2014 U.S. Dist. LEXIS 108503 (W.D. Wash. Aug. 6, 2014) involved a class action suit in which plaintiffs alleged Premera Blue Cross, imposed treatment limitations on applied behavior analysis and neurodevelopmental therapy when similar limitations were not applied to medical benefits in violation of Washington’s Mental Health Parity Act.  Premera agreed to a settlement in which it would remove the limitations and establish a $3.5 million settlement fund to reimburse plaintiffs who were denied services under the limitation.  The court approved the unopposed class settlement as fair, reasonable, and adequate.

The trend of cases reveal practical considerations some insureds may encounter in bringing suit against their health insurance company if benefits are small, and additional difficulties establishing a class action suit.  However, these decisions reflect the Ninth Circuit Court’s interpretation of the MH Parity Act, its willingness to hold health insurance carriers responsible for violations and ensure that insureds who have health insurance coverage have a viable claims for violations of the MH Parity Act.