A.Z. ex rel. Juno Therapeutics, Inc. v. Blueshield

333 F. Supp. 3d 1069
CourtDistrict Court, W.D. Washington
DecidedAugust 9, 2018
DocketC17-1292 TSZ
StatusPublished
Cited by28 cases

This text of 333 F. Supp. 3d 1069 (A.Z. ex rel. Juno Therapeutics, Inc. v. Blueshield) is published on Counsel Stack Legal Research, covering District Court, W.D. Washington primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
A.Z. ex rel. Juno Therapeutics, Inc. v. Blueshield, 333 F. Supp. 3d 1069 (W.D. Wash. 2018).

Opinion

Thomas S. Zilly, United States District Judge

THIS MATTER comes before the Court on the defendants' Motion to Dismiss, docket no. 40 (the "Motion").1 Having reviewed *1072all papers filed in support of, and in opposition to, the Motion,2 including the notices of supplemental authority submitted by the parties, see docket nos. 47-49, the Court enters the following order.

Background

I. Introduction

Plaintiff A.Z. ("A.Z.") is a 16-year-old female who was diagnosed with depression. Amended Complaint at ¶¶ 5, 17. Following her doctors' recommendation, she attended an outdoor residential mental health program in Oregon. Id. at ¶ 19. She sought reimbursement for the costs of the program under her parents' health benefit plan, but was denied. A.Z., by and through her parents and guardians and on behalf of the Juno Therapeutics, Inc. Health Benefit Plan (the "Plan"),3 brings this putative class action against defendants Regence Blueshield ("Regence") and Cambria Health Solutions Inc. ("Cambria" and, collectively with Regence, "Defendants")4 seeking remedies under the Employee Retirement Income Security Act of 1974 ("ERISA") for Regence's alleged failure to comply with the terms of the Plan and denial of coverage for the services she received at the outdoor mental health program she attended. See Amended Complaint at ¶¶ 1-4.

Regence underwrote, insured, and administered the Plan's health benefits until January 1, 2017. Amended Complaint at ¶ 7. A.Z. is a beneficiary of the Plan whose coverage is through her parent's employment with Juno Therapeutics, Inc. Id. at ¶ 5. A.Z.'s depression reached a level that "required treatment at a licensed outdoor/wilderness behavioral healthcare program." Id. at ¶¶ 17-18. Her doctors recommended that she receive behavioral health treatment at "Evoke, an outdoor residential mental health program in Oregon." Id. at ¶ 19.

II. A.Z.'s Requested Coverage

A.Z. sought preauthorization from Regence for the Evoke treatment, but Regence denied her request. Id. at ¶¶ 29-30. Regence explained that A.Z.'s participation in a wilderness program was not subject to preauthorization or eligible for benefits because it was excluded from the Plan. Id. at ¶ 30, Ex. C. Unable to delay her treatment, A.Z. began the Evoke wilderness program and appealed Regence's denial of coverage. Id. at ¶¶ 34, 38. Regence denied the appeal, reaffirming that the Plan does not cover the requested services and "specifically excludes wilderness therapy programs from coverage." Id. at ¶¶ 35, 39. By the time she completed her treatment at Evoke, A.Z. had incurred nearly $50,000 in expenses, which Regence refused to reimburse. See Amended Complaint, Exhibit 11 (periodic statements submitted by Evoke).

III. The Evoke Wilderness Program

The State of Oregon licenses Evoke as an "outdoor youth program." Id. at ¶ 20, Exhibit B ("Certificate of Approval to Operate a Child Caring Agency"). Evoke's licensing certificate confirms that it is authorized to operate its program "under provisions of *1073Oregon Revised Statutes 418.205 to 418.327 and related statutes ...." Id. , Exhibit B. Because it is a certified "outdoor youth program," Evoke is authorized by statute to provide, in an outdoor living setting, services to children who have mental health problems. Id.

Consistent with its statutory authority, Evoke's wilderness program "is a personal intervention that utilizes nature, small-group outdoor living, backpacking, one-on-one therapy, and group therapy." Evoke Therapy Programs, Wilderness Therapy (March 2017), https://evoketherapy.com/assets/Uploads/Wilderness-Therapy-3-17.pdf. Among other services, Evoke's wilderness program provides therapy from "experienced Master's or Ph.D. level therapists" who "create customized treatment plans for each participant and their families and offer guidance and support to meet their unique challenges." Id.

IV. A.Z.'s Claims for Relief

A.Z. now brings suit under ERISA, on behalf of a putative class, contending that Defendants have improperly denied benefits under the Plan and breached their fiduciary duties to adjudicate benefits determinations in violation of applicable law, including the Paul Wellstone and Pete Domenici Mental Health Parity and Addition Equity Act, see 29 U.S.C. § 1185a (the "Parity Act"), and the Affordable Care Act (the "ACA"), 42 U.S.C. § 300gg-5(a) ; 29 U.S.C. § 1185d. See Amended Complaint at ¶¶ 2-4, 63-73, 98-103.

A.Z. asserts four claims. Her first claim alleges that Defendants' denial of the costs of attending the Evoke wilderness program was improper under ERISA and seeks to recover any benefits due, along with a declaration of rights to coverage. Id. at ¶¶ 84-88. Her second claim asserts that Defendants' improper denial of coverage was a breach of Defendants' fiduciary duties imposed by ERISA. Id. at ¶¶ 89-95. Her third claim seeks to enforce the Plan, alleges a violation of the Parity Act and the ACA, and seeks to recover the benefits due to A.Z. under the Plan. Id. at ¶¶ 96-103. Her fourth claim asks for equitable remedies under ERISA for Defendants' violation of the Parity Act and the ACA. Id. at 104-06.

Defendants put forth three primary arguments in support of their Motion seeking dismissal of the Amended Complaint under Federal Rule of Civil Procedure 12(b)(6). First, Defendants argue that A.Z. has failed to allege sufficient facts establishing that the Plan covered the Evoke wilderness program in the first instance, thereby precluding recovery. Motion at 1, 7-11. Second, Defendants contend that the "Counseling in the Absence of Illness" exclusion expressly excludes coverage for the Evoke wilderness program. Id. at 1, 11-12. Third, Defendants argue that A.Z. has failed to adequately plead Parity Act and ACA violations. Id. at 13-21.

Discussion

I. Motion to Dismiss Standard

A complaint challenged by a Rule 12(b)(6) motion to dismiss must offer "more than labels and conclusions" and contain more than a "formulaic recitation of the elements of a cause of action." Bell Atl. Corp. v. Twombly , 550 U.S. 544, 555, 127 S.Ct. 1955

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Bluebook (online)
333 F. Supp. 3d 1069, Counsel Stack Legal Research, https://law.counselstack.com/opinion/az-ex-rel-juno-therapeutics-inc-v-blueshield-wawd-2018.