Thursday, December 27, 2018

A federal district court in Florida granted Aetna’s motion to dismiss claims that it violated ERISA and the Mental Health Parity and Addiction Act of 2008 (MHPAA) by refusing to cover the cost of wilderness therapy programs in Colorado and Utah. The court determined that the plaintiffs failed to state a plausible claim under their respective plans because they did not allege facts sufficient to show that the wilderness therapy programs qualified for coverage under the terms of their plans.

One of the plans covered treatment performed at a “residential treatment facility” and listed detailed requirements a facility must meet to qualify for coverage. The court found that the complaint did not contain sufficient information to show that the wilderness program met those requirements; there were no allegations that the program had licensed behavioral providers on site at all hours, or that access to necessary medical services was always available, among other things. The other plan covered “residential treatment services,” defined in relevant part as services that are licensed in accordance with the laws of the “appropriate legally authorized agency.” The court dismissed the claims because the complaint alleged that the wilderness plan was licensed under Utah law as an “outdoor youth treatment program,” rather than as a “residential treatment service,” thus failing to meet the plan’s requirements.

The court also dismissed the MHPAA claims due to a lack of factual allegations to support them. First, plaintiffs brought a categorical challenge that Aetna “excluded all coverage for mental health treatment received at residential treatment center programs,” but covered medical and surgical services received at skilled nursing facilities. The court found, however, that the plans’ terms plainly provided coverage for treatment by residential treatment center programs. Second, plaintiffs alleged that the plans did not impose similar definitional requirements for skilled nursing facilities and residential treatment facilities. The court determined that those allegations were insufficient because the complaint did not allege what criteria Aetna required of skilled nursing facilities. Third, plaintiffs argued that Aetna used different standards in assessing medical services rendered at residential treatment center programs than the standards used to assess services rendered at skilled nursing facilities. The court found this allegation “conclusory” and “unsupported by anything in the complaint.”

The case is H.H. v. Aetna Insurance Co., 2018 WL 6614223 (S.D. Fla. Dec. 13, 2018).