Gallagher v. Empire Healthchoice Assurance, Inc.

339 F. Supp. 3d 248
CourtDistrict Court, S.D. Illinois
DecidedSeptember 11, 2018
Docket16 Civ. 9105 (PGG)
StatusPublished
Cited by25 cases

This text of 339 F. Supp. 3d 248 (Gallagher v. Empire Healthchoice Assurance, Inc.) is published on Counsel Stack Legal Research, covering District Court, S.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Gallagher v. Empire Healthchoice Assurance, Inc., 339 F. Supp. 3d 248 (S.D. Ill. 2018).

Opinion

Paul G. Gardephe, United States District Judge

Plaintiff William Gallagher brings this action against Empire HealthChoice Assurance, Inc. ("Empire") under Section 502 of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132, challenging Empire's denial of mental health benefits for wilderness therapy provided to his sixteen-year-old daughter "J.G." (Cmplt. (Dkt. No. 5) ) Plaintiff alleges that Empire's categorical exclusion of wilderness therapy violates the Mental Health Parity and Addiction Equity Act (the "Parity Act"). (Id. ¶ 16) The Complaint pleads two ERISA-based benefit claims: a claim for plan enforcement under 29 U.S.C. § 1132(a)(1)(B), and a claim for breach of fiduciary duty under 29 U.S.C. § 1132(a)(3). (Id. ¶ 27-36)

Empire has moved to dismiss and to strike Plaintiff's jury demand. (Def. Mot. (Dkt. No. 20) at 1)1 For the reasons stated below, Empire's motion to dismiss will be granted in part and denied in part, and Empire's motion to strike the jury demand will be granted.

BACKGROUND

I. RELEVANT PLAN PROVISIONS

Plaintiff is an employee of Mount Sinai Health System - a New York City-based *251hospital and health care company - and receives health insurance benefits through an employer-sponsored health insurance plan (the "Plan"). (Cmplt. (Dkt. No. 5) ¶¶ 2-3, 7) The Plan is administered by Empire - a not-for-profit managed care subsidiary of Anthem, Inc. that administers employer-funded health insurance plans. (Id. ¶¶ 7-8) Under the Plan, Mount Sinai is responsible for benefit payments, and Empire "provides administrative claims payment services only[.]" (Cmplt., Ex. A (Health Plan) (Dkt. No. 5-1) at 3) As claims administrator, Empire has discretionary authority to interpret and apply the Plan's terms in reviewing claims and determining benefit entitlement. (Cmplt. (Dkt. No. 5) ¶ 8) Under ERISA, 29 U.S.C. § 1002(7) - (8), Plaintiff is a Plan participant and J.G. is a Plan beneficiary. (Id. ¶¶ 2, 7)

Under the Plan, Empire is directed to authorize benefits for Covered Services as long as the service sought is "Medically Necessary." (Cmplt., Ex. A (Health Plan) (Dkt. No. 5-1) at 85) The Plan provides that Empire will determine whether a Covered Service is "Medically Necessary" based on

Your medical records;
[Empire's] medical policies and clinical guidelines;
Medical opinions of a professional society; peer review committee or other groups of Physicians;
Reports in peer-reviewed medical literature;
Reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data;
Professional standards of safety and effectiveness, which are generally-recognized in the United States for diagnosis, care, or treatment;
The opinion of Health Care Professionals in the generally-recognized health specialty involved;
The opinion of attending Providers, which have credence but do not overrule contrary opinions.

(Id. )

The Plan further provides that "Services will be deemed Medically Necessary only if":

They are clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for Your illness, injury, or disease;
They are required for the direct care and treatment or management of that condition;
Your condition would be adversely affected if the services were not provided;
They are provided in accordance with generally accepted standards of medical practice;
They are not primarily for convenience of You, Your family, or Your Provider;
They are not more costly than an alternative service or sequence of services, that is at least as likely to produce equivalent therapeutic or diagnostic results;
When setting or place of service is part of the review, services that can be safely provided to You in a lower cost setting will not be Medically Necessary if they are performed in a higher cost setting....

(Id. at 85-86)

The Plan's Covered Services include mental health and substance abuse treatments. (Id. at 47) The "Behavioral Healthcare" section of the Plan states that, "[i]n addition to the services listed in Your Benefits At A Glance section, the following mental health care service is covered":

• Electroconvulsive therapy for treatment of mental or behavioral disorders, if precertified by Behavioral Healthcare Management.
*252• Care from psychiatrists, psychologists or licensed clinical social workers, providing psychiatric or psychological services within the scope of their practice, including the diagnosis and treatment of mental and behavioral disorders. Social workers must be licensed by the New York State Education Department or a comparable organization in another state, and have three years of post-degree supervised experience in psychotherapy and an additional three years of post-licensure supervised experience in psychotherapy.
• Treatment in a New York State Health Department-designated Comprehensive Care Center for Eating Disorders pursuant to Article 27-J of the New York State Public Health Law.
• We Cover inpatient mental health care services relating to the diagnosis and treatment of mental, nervous and emotional disorders received at Facilities that provide residential treatment, including room and board charges.

The Your Benefits At A Glance section states that the Plan covers mental health care - and alcohol or substance abuse treatment - on both an outpatient and an inpatient basis. (Id. at 26) The Plan does not specifically mention wilderness therapy. (Cmplt. (Dkt. No. 5) ¶ 10)

Empire makes the initial determination as to a claim for benefits under the Plan, and also is responsible for addressing "Level 1 Appeals." (Id., Ex. A (Health Plan) (Dkt. No.

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

Related

Cite This Page — Counsel Stack

Bluebook (online)
339 F. Supp. 3d 248, Counsel Stack Legal Research, https://law.counselstack.com/opinion/gallagher-v-empire-healthchoice-assurance-inc-ilsd-2018.