H.H. v. Aetna Ins. Co., 2018 WL 6614223 (S.D. Fla. 2018)

A federal court has dismissed a lawsuit against a claims administrator for its denial of benefits for mental health treatment provided at two different wilderness therapy facilities under two different employer-sponsored health plans. The plan participants sued for enforcement of their plans’ terms under ERISA and for violation of the federal mental health parity requirements. The court ruled first on the ERISA claims, finding that the participants had not shown that the wilderness programs met the requisite definitions and criteria to be covered under the terms of the plans. The participants argued that the programs were covered under plan provisions providing coverage for residential facilities for treatment of mental disorders and substance abuse. However, the participants were unable to show that the programs met the plans’ criteria for residential treatment facilities because they lacked licensed behavioral health providers on site, comprehensive patient assessments upon admission, patient admission by a physician, round-the-clock access to necessary medical services, and proper licensure.

Addressing the mental health parity claims, the court explained that parity violations may occur on either a categorical or as-applied basis and dismissed the participants’ arguments as to both. The court found no categorical violation because the plan clearly covered treatment at residential mental health treatment programs along with medical and surgical treatment at skilled nursing facilities. And there was no as-applied violation because the participants did not sufficiently allege that the claims administrator had a standard practice of denying coverage for mental health or substance abuse services at residential treatment centers. According to the court, the participants’ allegations that the administrator used different criteria in evaluating claims for residential mental health treatment as opposed to skilled nursing care were conclusory and unsupported. The court dismissed the case but noted that the participants were free to file an amended complaint with more specific allegations.

EBIA Comment: Plan exclusions of residential mental health treatment in a wilderness setting continue to generate litigation. (See, for example, our Checkpoint articles on Gallagher, Vorpahl, and A.Z.) Although plan participants have met with varying degrees of success, the attention generated by these cases—along with the DOL’s focus on mental health parity enforcement (see our Checkpoint article)—suggests that more cases will follow. For more information, see EBIA’s Group Health Plan Mandates manual at Sections IX.A (“What Is Mental Health Parity and Who Must Comply?”), IX.E (“Mental Health Parity: Nonquantitative Treatment Limitations”), and IX.K (“Mental Health Parity: Table of Cases”). See also EBIA’s Self-Insured Health Plans manual at Sections XIII.C (“Federally Mandated Benefits”) and XIII.E (“Coverage Limitations and Exclusions”).

Contributing Editors: EBIA Staff.