Craft v. Health Care Service Corp.

84 F. Supp. 3d 748, 2015 U.S. Dist. LEXIS 37926, 2015 WL 1399047
CourtDistrict Court, N.D. Illinois
DecidedMarch 25, 2015
DocketNo. 14 C 5853
StatusPublished
Cited by4 cases

This text of 84 F. Supp. 3d 748 (Craft v. Health Care Service Corp.) is published on Counsel Stack Legal Research, covering District Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Craft v. Health Care Service Corp., 84 F. Supp. 3d 748, 2015 U.S. Dist. LEXIS 37926, 2015 WL 1399047 (N.D. Ill. 2015).

Opinion

MEMORANDUM OPINION AND ORDER

Virginia M. Kendall, United States District Court Judge

Before the court is defendant- Health Care Service Corporation’s (“HCSC”) motion to dismiss. For the following reasons, the court denies HCSC’s motion.

Plaintiff Elizabeth A. Craft is an employee of Trustwave Holdings, Inc. and a participant in The Trustwave Holdings, Inc. Health Care Benefit Plan (the “Trust-wave Plan”). (ComplJ 3.) Defendant HCSC, operating as Blue Cross and Blue Shield of Illinois, administers and insures the plan. (Id. at ¶ 2.) Doctors have diagnosed Craft’s 16-year-old daughter, plaintiff Jane Doe, with post-traumatic stress disorder, recurrent, severe major depressive disorder, and anorexia nervosa. (Id. at ¶ 12.) Since August 2012, Jane has been hospitalized nine times for acute inpatient care to treat her mental illness. (Id. at ¶ 13.) On each occasion, Jane’s treating physicians have recommended that she be transferred to a long-term residential treatment center (“RTC”) upon discharge from the hospital. (Id. at ¶ 14.) On July 17, 2014, HCSC denied Craft’s request to preauthorize RTC treatment pursuant to the following exclusion in the Trustwave Plan (“the RTC exclusion”):

Expenses for the following are not covered under your benefit program ... Residential Treatment Centers, except for Inpatient Substance Abuse Rehabilitation Treatment....

(Trustwave Plan, attached as Ex. 1 to Def.’s Mem. in Supp. of Mot. to Dismiss (“Def.’s Mem.”), at 90, 93.)1 There is no corresponding exclusion for treatment of [750]*750medical and surgical conditions in similar residential facilities (e.g., “Skilled Nursing Facilities”). (See id. at 57; see also Compl. ¶ 1.) The plaintiffs claim that this exclusion violates provisions of the Employee Retirement Income Security Act of 1974 (“ERISA”) requiring parity between mental-health and medical/surgical benefits. (ComplA 1.) HCSC has moved to dismiss plaintiffs’ complaint on the ground that the statute did not apply to “treatment settings” during the relevant time period.

LEGAL STANDARD

“To survive a motion to dismiss under Rule 12(b)(6), a complaint must provide enough factual information to ‘state a claim to relief that is plausible on its face’ and ‘raise a right to relief above the speculative level.’ ” Thulin v. Shopko Stores Operating Co., LLC, 771 F.3d 994, 997 (7th Cir.2014) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555, 570, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007)). “Whether a complaint states a claim upon which relief may be granted depends upon the context of . the case and ‘requires the reviewing court to draw on its judicial experience and common sense.’ ” Id. (quoting Ashcroft v. Iqbal, 556 U.S. 662, 679, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009)). The court accepts the complaint’s well-pleaded allegations as true and construes them in the light most favorable to the plaintiffs. Id.

DISCUSSION

I. The Parity Act

In 1996, Congress enacted the Mental Health Parity Act of 1996 (“MHPA”), which required group health plans to impose the same aggregate lifetime and annual dollar limits for mental health benefits that such plans impose on medical/surgical benefits. See MHPA, Pub.L. No. 104-204, 110 Stat 2874 (current version at 29 U.S.C. § 1185a).2 In 2008, Congress passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (the “Parity Act”). See Parity Act, PL 110-343, 122 Stat. 3765 (codified at 29 U.S.C. § 1185a). The Parity Act extended the MHPA’s parity requirement to encompass: (1) “financial requirements” (e.g., copayments and deductibles); and (2) “treatment limitations.” 29 U.S.C. § 1185a(a)(3)(A)(i)-(ii), (B)(i). “The term ‘treatment limitation’ includes limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment.” Id. at § 1185a(a)(3)(B)(iii). To comply with the Parity Act, a plan must ensure that: (1) the treatment limitations applicable to mental-health benefits are “no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage);” and (2) “there are no separate treatment limitations that are applicable only with respect to [mental-health benefits].” Id. at § 1185a(a)(3)(A)(ii). Before the Act became effective for most plans, the Departments solicited comments from interested parties regarding the statute’s application. See Request for Information (“RFI”) Regarding the Pari[751]*751ty Act, 74 Fed.Reg. 19155 (Apr. 28, 2009). Among other things, the Departments asked interested parties to address treatment limitations other than those enumerated in the statute itself. Id. at 19157.

A. Interim Final Rules

After receiving responses to their RFI, the Departments published interim final rules (“IFRs”) in lieu of soliciting comments on a proposed rule. The Departments reasoned that the IFRs were necessary because “without prompt guidance some members of the regulated community may not know what steps to take to comply with” the Parity Act’s requirements. See Preamble, IFRs Under the Parity Act, 75 Fed.Reg. 5410-01, 5419 (Feb. 2, 2010). The IFRs applied the term “treatment limitations” to both “quantitative” and “nonquantitative” limitations. 29 C.F.R. § 2590.712 (amended Jan. 13, 2014).3 With respect to particular “types” of limitations — e.g., copay-ments — the IFRs required parity between mental-health benefits and medical/surgical benefits within the same “classification.” Id. at § 2590.712(c)(l)(i)-(ii). The IFRs established six such classifications: (1) inpatient, in-network; (2) inpatient, out-of-network; (3) outpatient, in-network; (4) outpatient, out-of-network; (5) emergency care; and (6) prescription drugs. Id. at § 2590.712(c)(2)(ii). The IFRs included an “[illustrative list” of types of nonquantitative treatment limitations:

Nonquantitative treatment limitations include:

(A)Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative;
(B) Formulary design for prescription drugs;
(C) Standards for provider admission to participate in a network, including reimbursement rates;
(D) Plan methods for determining usual, customary, and reasonable charges;

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
84 F. Supp. 3d 748, 2015 U.S. Dist. LEXIS 37926, 2015 WL 1399047, Counsel Stack Legal Research, https://law.counselstack.com/opinion/craft-v-health-care-service-corp-ilnd-2015.