J.T. v. Regence Blueshield

291 F.R.D. 601, 2013 WL 2444717, 2013 U.S. Dist. LEXIS 79672
CourtDistrict Court, W.D. Washington
DecidedJune 4, 2013
DocketNo. C12-90 RAJ
StatusPublished
Cited by2 cases

This text of 291 F.R.D. 601 (J.T. v. Regence 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
J.T. v. Regence Blueshield, 291 F.R.D. 601, 2013 WL 2444717, 2013 U.S. Dist. LEXIS 79672 (W.D. Wash. 2013).

Opinion

ORDER

RICHARD A. JONES, District Judge.

INTRODUCTION

The court has before it three pending motions. Dkt. ## 15, 28, 29. On November 29, 2012, defendants Regence BlueShield and Cambria Health Solutions, Inc., f/k/a The Regence Group (“Defendants”) filed a Fed. R.Civ.P. 12(b)(1) motion to dismiss for lack of subject matter jurisdiction. Dkt. # 15. Plaintiffs J.T. and S.A. (“Plaintiffs”) oppose the motion. Dkt. # 18. While that motion was pending, Plaintiff S.A. filed a motion for class certification, as well as a motion for partial summary judgment for declaratory and injunctive relief. Dkt. ##28, 29. Defendants oppose those motions. Dkt. ## 52-1, 53-1.1 Having considered the memoranda, exhibits, oral argument, and the record herein, the court DENIES Defendants’ motion to dismiss for lack of subject matter jurisdiction (Dkt. # 15), DENIES S.A’s motion for class certification (Dkt. # 28), and DENIES S.A.’s motion for partial summary judgment (Dkt. #29).

BACKGROUND

Plaintiffs filed suit on January 17, 2012, alleging that Defendants have failed to comply with Washington’s Mental Health Parity Act (“Parity Act”). Dkt. # l.2 They contend that the health care plans underwritten by Defendants do not provide coverage for Plaintiffs’ medically necessary neurodevelop-mental therapy,3 thus violating the mandates of the Parity Act. Dkt. # 10 (Amended Complaint (“FAC”)) ¶¶ 10-16. The Employee Retirement Income Security Act (“ERISA”) governs the health care plans at issue, and thus Plaintiffs bring their claims under its provisions. See 29 U.S.C. § 1002(1). Plaintiffs’ amended complaint sets forth three claims for relief: (1) breach of fiduciary duties pursuant to ERISA § 404(A)(1), 29 U.S.C. § 1104(A); (2) recovery of benefits, clarification of rights under terms of the plan, and clarification of rights to future benefits under the plan pursuant to ERISA § 503(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B); and (3) to enjoin acts and practices in violation of the terms of the plans, to obtain other equitable relief, and to enforce the terms of the plans pursuant to ERISA § 503(a)(3), 29 U.S.C. § 1132(a)(3). Dkt. # 10 ¶¶ 31-44.

A. Plaintiff J.T.

J.T., who was 10 years old when Plaintiffs filed this case, is the son of K.T. and R.T. Dkt. #10 ¶ 1. J.T. is a beneficiary of the Puget Sound Energy, Inc. Health Plan, which was underwritten and administered by Regence BlueShield (“Regence”) until December 31, 2011. Id. ¶¶ 1, 5. J.T. has been diagnosed with Articulation Disorder and Re-eeptive/Expressive Language Disorder, conditions included in the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. [605]*605Text Revision (“DSM-IV-TR”). Dkt. # 21-1 (Ex. A. to K.T. Decl.) at 2. In 2009 and 2010, J.T. received neurodevelopmental speech therapy to treat these disorders. Dkt. ## 21 (K.T. Decl.) ¶¶ 2-3; 21-1 at 2, 7 (Exs. A, B to K.T. Decl.). K.T. and R.T. submitted claims for J.T.’s treatment to Regence, but Regence would not pay for any part of J.T.’s neurodevelopmental therapy. Dkt. ## 21 ¶ 3; 21-1 at 9-15 (Ex. C to K.T. Deck). Pursuant to the “Neurodevelopmental Therapy Services” provision of J.T.’s plan, neuro-developmental services (speech, physical, and occupational therapy) are provided only to beneficiaries age six and younger. Dkt. # 17 at 26 (Ex. A to Garrett Deck). K.T. and R.T. appealed Regence’s denial of the claims, but on December 10, 2009, they received a letter from Regence stating that J.T. was “not eligible for this coverage because it is limited to children under the age of seven.” Dkt. #21-1 at 17 (Ex. D to K.T. Deck). They again appealed, and Regence responded by reiterating that J.T. was not eligible for coverage due to his age. Dkt. # 21-1 at 20 (Ex. E to K.T. Deck).

B. Plaintiff S.A.

S.A. is the daughter of A.K. Dkt. #20 (A.K. Deck) ¶ 2. She is a beneficiary of the Disability Rights Washington (“DRW”) Health Benefit Plan, which is underwritten and administered by Regence. Dkt. # 10 ¶¶ 2, 5. She was born with Down Syndrome. Dkt. #20 ¶ 2. S.A’s health care plan provides coverage for neurodevelopmental therapy only to beneficiaries “age six and under with a neurodevelopmental delay.” Dkt. # 17-2 (Ex. D to Garrett Deck) at 22. The plan defines “neurodevelopmental delay” as “a delay in normal development that is not related to any documented Illness or Injury.” Id. “Illness” is defined as “a congenital malformation that causes functional impairment; a condition, disease, ailment, or bodily disorder.” Id. at 74. S.A.’s plan also provides coverage for rehabilitation services, which are described as “physical, occupational, and speech therapy services ... necessary to restore or improve lost function caused by Injury or Illness.” Id. at 24. Both benefits place an annual cap on coverage for outpatient services at $1500. Id. at 22,24.

In July 2010, A.K. wrote to Regence and asked whether her health plan would cover speech therapy for her 16-year-old “daughter with Down syndrome.” Dkt. # 20-1 at 8 (Ex. C to A.K. Deck). She received no response. Dkt. #20 ¶ 4. In November 2010, S.A. obtained a “School-Age Speech & Language Evaluation” from the Evergreen Speech & Hearing Clinic (“ESHC”). Dkt. # 20-1 at 2-4 (Ex. A to A.K. Deck). Kara Leach, a Speech-Language Pathologist at ESHC, diagnosed S.A. with Developmental Articulation Disorder and Expressive/Reeep-tive Language Disorder, both of which are mental health disorders included in the DSM-IV-TR.4 Dkt. # 20-1 at 2. Leach recommended that “[d]ue to the presence of’ these disorders, S.A. should receive “speech and language therapy twice weekly for four to six months depending upon [her] need.” Dkt. # 20-1 at 4; see also id. at 6 (Ex. B to A.K. Deck) (medical prescription dated November 26, 2010, for “speech therapy 2x/ wk”). On November 22, 2010, “Lisa” from ESHC called Regence customer service to determine whether S.A. had speech therapy benefits available. Dkt. # 34-1 at 20 (Ex. C to Hamburger Deck). Lisa provided the billing codes for Down Syndrome and the two relevant speech disorders.5 Dkt. #34-1 at 20. The customer service representative asked Lisa whether the therapy was “to restore function lost due to illness or injury.” Dkt. #34-1 at 21. Lisa responded that “there was no illness or injury,” and that “it has to do with the Down’s Syndrome.” Dkt. # 34-1 at 21. The representative stated, “So that’s considered like neurodevelopmental therapy,” and thus would be covered only up to age six. Dkt. # 34-1 at 21. Lisa responded that she “wasn’t sure because of the Down’s Syndrome diagnosis, if that would [606]*606fall under the rehab[ilitation] benefit.” Dkt. #34-1 at 21. The representative replied, “Yeah, it doesn’t.” Dkt. # 34-1 at 21.6 However, two days later ESHC submitted a claim for the cost of the evaluation to Re-gence, which Regence paid. Dkt. # 17-1 at 65-66 (Ex. B to Garrett Deck).

On February 16, 2011, A.K.

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Cite This Page — Counsel Stack

Bluebook (online)
291 F.R.D. 601, 2013 WL 2444717, 2013 U.S. Dist. LEXIS 79672, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jt-v-regence-blueshield-wawd-2013.