A.G. ex rel. Situated v. Cmty. Ins. Co.

363 F. Supp. 3d 834
CourtDistrict Court, S.D. Ohio
DecidedJanuary 28, 2019
DocketCase No. 1:18-cv-300
StatusPublished
Cited by6 cases

This text of 363 F. Supp. 3d 834 (A.G. ex rel. Situated v. Cmty. Ins. Co.) is published on Counsel Stack Legal Research, covering District Court, S.D. Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
A.G. ex rel. Situated v. Cmty. Ins. Co., 363 F. Supp. 3d 834 (S.D. Ohio 2019).

Opinion

Timothy S. Black, United States District Judge

This civil action is before the Court upon Defendant Community Insurance Company d/b/a/ Anthem Blue Cross Blue Shield ("Anthem" or "Defendant")'s Partial Motion to Dismiss Counts 1-3 of Plaintiff's class action complaint (Doc. 10) and the parties' responsive memoranda (Docs. 21 and 22).

I. FACTS AS ALLEGED BY THE PLAINTIFF

For purposes of this motion to dismiss, the Court must: (1) view the complaint in the light most favorable to Plaintiffs; and (2) take all well-pleaded factual allegations as true. Tackett v. M & G Polymers , 561 F.3d 478, 488 (6th Cir. 2009).

*836This is an Employee Retirement Income and Security Act ("ERISA") action arising from Defendant's decision to deny health plan benefits for allegedly medically necessary services for wilderness behavioral health treatment for mental health and substance abuse issues. (Doc. 1 at ¶ 1). During the relevant time period, N.G., the father of A.G., was an insured by Defendant through his employer-sponsored health insurance. (Id. at ¶ 7).1

A.G. has struggled for years with mental health issues such as depression, anxiety, eating disorders, suicide ideations, and drug use. (Id. at ¶ 10). After counseling, hospitalization, and other therapies were unsuccessful, A.G. was sent to Blue Ridge Therapeutic Wilderness ("Blue Ridge"). (Id. ). Blue Ridge is an outdoor/behavioral therapy program located in Clayton, Georgia. (Id. ). Blue Ridge is an intermediate care program licensed by the state of Georgia as an "Outdoor Child Caring Program" that treats youths with mental health and substance abuses diagnoses. (Id. at ¶ 12). Blue Ridge uses a multidisciplinary approach to treat youths with mental health and substance abuses diagnoses, using wilderness behavioral healthcare therapy to deliver traditional, evidence-based treatments. (Id. at ¶ 14). On intake, Blue Ridge patients receive a psychiatric assessment and receive tailored personal treatment including individual therapy, group therapy, and family therapy. (Id. at ¶ 14).

A.G. received treatment at Blue Ridge from January 5, 2017 to March 31, 2017. (Id. at ¶ 16). N.G. personally paid $ 46,650 for the Blue Ridge services. (Id. ). On October 16, 2017, Anthem denied the claims submitted for A.G.'s treatment at Blue Ridge based on a plan provision that excludes claims for "wilderness camps." (Id. at ¶ 17).

The Plan requires one level of internal appeal, and thus the October 16, 2017 denial, which came in response to an appeal, exhausted the internal appeals process. (Id. at ¶ 18). Anthem had full discretionary authority to administer and pay benefits under the plan. (Id. at ¶ 9).

Under the terms of the Plan, Anthem is required to pay benefits for "Covered Services." (Id. at ¶ 58; Doc. 1-2 at M3, M-22). Covered Services are those "performed, prescribed, directed or authorized by a Provider." (Doc. 1-2 at M-112). The Plan defines "Provider" as "[a] duly licensed person or facility...." (Id. at M-117). The Plan defines "Facility" as:

a facility including but not limited to, a Hospital, freestanding Ambulatory Surgical Facility, Chemical Dependency Treatment Facility, Residential Treatment Center, Skilled Nursing Facility, Home Health Care Agency or mental health facility, as defined in this Certificate. The Facility must be licensed, accredited, registered or approved by the Joint Commission or the Commission on Accreditation of Rehabilitation Facilities (CARF), as applicable, or meet specific rules set by [Defendant].

(Id. at M-118).

Covered Services are subject to conditions, Exclusions, limitations, terms, and provisions of the Plan. (Id. at M-22). The Plan states that excluded services are not covered "even if the service, supply, or equipment would otherwise be considered Medically Necessary." (Id. ). Medically Necessary is a service known to be effective, as proven by scientific evidence, in materially improving health outcomes; the *837most appropriate supply, setting or level of service that can safely be provided that cannot be omitted consistent with recognized professional standards of care; cost-effective compared to alternative interventions, not experimental; not primarily for the convenience of the insure; and not otherwise excluded. (Doc. 1 at ¶ 35; see Doc. 1-2 at M-114-115).

The pertinent portion of the "Non Covered Services/Exclusions" section of the Plan, under which Plaintiff's claim was denied, provides:

We do not provide benefits for procedures, equipment, services, supplies or charges:
...
• Custodial Care, convalescent care or rest cures.
• Domiciliary care provided in a residential institution, treatment center, supervised living or halfway house, or school because a Member's own home arrangements are not available or are unsuitable, and consisting chiefly of room and board, even if therapy is included.
• Care provided or billed by a hotel, health resort, convalescent home, rest home, nursing home or other extended care facility home for the aged, infirmary, school infirmary, institution providing education in special environments, supervised living or halfway house, or any similar facility or institution.
• Services or care provided or billed by a school, Custodial Care center for the developmentally disabled, halfway house, or outward bound programs, even if psychotherapy is included.
• Wilderness camps.

(Doc 1-2 at M-55, M-57, ¶ 22).

The Plan does cover behavioral/mental health services at "Residential Treatment" in "a licensed Residential Treatment Center that offers individualized and intensive treatment that includes observation and assessment by a physician weekly or more often and rehabilitation, therapy, and education." (Id. at M-24). The Plan defines a "Residential Treatment Center" as:

A Provider licensed and operated as required by law, which includes:
1. Room, board and skilled nursing care (either an RN or LUN/LPN) available on-site at least eight hours daily with 24 hour availability;
2. A staff with one or more Physicians available at all times.
3. Residential treatment takes place in a structured facility-based setting.
4. The resources and programming to adequately diagnose, care and treat a psychiatric and/or substance use disorder.
5. Facilities are designated residential, subacute, or intermediate care and may occur in care systems that provide multiple levels of care.
6.

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Bluebook (online)
363 F. Supp. 3d 834, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ag-ex-rel-situated-v-cmty-ins-co-ohsd-2019.