Karen L. v. Physicians Health Services, Inc.

202 F.R.D. 94, 2001 WL 897367
CourtDistrict Court, D. Connecticut
DecidedJuly 30, 2001
DocketNo. CIV.A. 3:99 CV 2244CFD
StatusPublished
Cited by7 cases

This text of 202 F.R.D. 94 (Karen L. v. Physicians Health Services, Inc.) is published on Counsel Stack Legal Research, covering District Court, D. Connecticut primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Karen L. v. Physicians Health Services, Inc., 202 F.R.D. 94, 2001 WL 897367 (D. Conn. 2001).

Opinion

RULING ON PLAINTIFF’S MOTION FOR CLASS CERTIFICATION

DRONEY, District Judge.

The plaintiffs bring this suit pursuant to 42 U.S.C. § 1983 against Physicians Health Services, Inc. (“PHS”) and Patricia Wilson-Coker, in her capacity as Commissioner of the State of Connecticut Department of Social Services (“the Commissioner”), alleging violations of the federal Medicaid statute, 42 U.S.C. § 1396a(a)(3), and the Due Process Clause of the Fourteenth Amendment to the U.S. Constitution. The plaintiffs also claim that defendant PHS violated the Connecticut Unfair Trade Practices Act, Conn.Gen.Stat. § 42-110a, et seq. (“CUTPA”) and the Connecticut Unfair Insurance Practice Act, Conn.Gen.Stat. § 38a-815, et seq. (“CUIPA”).

PHS is a managed care organization that contracts with the Department of Social Services (“DSS”) to provide health services covered under Connecticut’s Medicaid plan to recipients enrolled in its plan. The plaintiffs challenge the alleged failure of both defendants to provide adequate written notice of adverse actions taken in regard to coverage claims made by enrollees in PHS’s Medicaid-managed care plans, and their alleged failure to ensure that such Medicaid enrollees can apply for, and be furnished with, prescription drug benefits without delay.1 They attribute this delay to inadequacies in the operation of PHS’ pharmacy benefits policy, and in particular, its preferred drug formulary system.2 The plaintiffs also challenge the alleged failure of the Commissioner to ensure that the [97]*97enrollees are afforded adequate hearing rights to challenge denials of coverage.

In addition to declaratory relief pursuant to 28 U.S.C. §§ 2201 and 2202, the plaintiffs seek an injunction requiring:

(1) That PHS provide adequate written notices to Medicaid managed care en-rollees at the time of actions taken concerning their claims for services;
(2) That the Commissioner take all actions necessary to ensure that PHS provide such notices;
(3) That the Commissioner provide an expedited state fair hearing to enrollees to challenge decisions by PHS;
(4) That PHS ensure that its Medicaid enrollees are able to apply for, and be furnished with, prescription drug benefits without delay; and
(5) That the Commissioner take all actions necessary to ensure that PHS permits its Medicaid enrollees to apply for, and be furnished with, prescription drug benefits without delay.

The plaintiffs also request an award of attorney’s fees under 42 U.S.C. § 1988.

Pending is the plaintiffs’ renewed and amended motion for class certification [Doc. # 125].3 It seeks certification of a class consisting of the following individuals: “All past, current, and future Medicaid recipients who were or currently are enrolled in, or who in the future will be enrolled in, any managed care plan offered by defendant PHS to Medicaid recipients, under contract with defendant Commissioner.” Am.Mot. Class Certification at 1-2. The plaintiffs contend that their claims satisfy the class action requirements of Rules 23(a) and (b)(2) of the Federal Rules of Civil Procedure. For the following reasons, the plaintiffs’ motion is GRANTED.

I. Background

The original named plaintiffs in this case are Karen L. and Grisel Hernandez. On February 14, 2001, the Court permitted two additional individuals, K.P. and A.M., to intervene as named plaintiffs and prosecute under fictitious names. All of the plaintiffs are Medicaid recipients whose health care coverage is provided by PHS.

A. Karen L.

According to the plaintiffs’ allegations, Karen L., a minor, sought mental health treatment under a PHS Medicaid plan to cope with past sexual abuse. On several occasions in 1998 and 1999, her therapist requested approval for several series of psychological counseling sessions. Coverage for each series was either denied or partially denied by PHS and its predecessor,4 through their behavioral health managed care subcontractor. Karen L.’s mother, Jane L., never received written notice of the denials and partial denials (though the therapist was informed of the sessions that were approved), was never informed of the reasons for the action taken, and never received information regarding her appeal rights concerning the denials of treatment.

B. Grisel Hernandez

Grisel Hernandez also sought coverage under a PHS Medicaid plan for an exploratory laparoscopic procedure related to a gynecological illness, which PHS denied without adequately indicating proper authority for that decision.

In addition, Hernandez alleges that she was twice refused prescription refills, and pharmacists informed her that PHS would not cover the prescription. According to the plaintiffs, she was not aware that if prior authorization had been obtained, she could have received the refills. She was never informed of the reasons for the denials, and [98]*98attributes this to defects in PHS’s policies relating to non-formulary medications that require prior authorization by a physician or pharmacist. Ms. Hernandez also claims that these defects in the drug formulary system prevented her from receiving her prescription with reasonable promptness, as required by Medicaid statutes.

C. K.P.

Plaintiff K.P., a minor, sought coverage for a topical anesthetic prescribed by his physicians, to relieve the pain of injections and intravenous treatment for several chronic medical conditions. The medication prescribed for K.P. apparently was not included in PHS’ formulary of pre-approved medications, but an alternative medication was on that list. PHS denied coverage for the prescribed medication through the use of a notice that the plaintiffs claim was deficient. The plaintiffs also contend that K.P. was never informed that a pre-approved alternative medication could have been substituted for the prescribed anesthetic.

In addition, K.P. alleges that his mother did not receive written notification of PHS’s decision to deny coverage for six hours of “case management” services performed by K.P.’s behavioral therapist, and that as a result of this lack of notice, she was unable to appeal the decision.5

D. A.M.

A.M. is a minor suffering from post-traumatic stress disorder, a condition for which her psychiatrist prescribed an anti-depressant medication.

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

Related

Cite This Page — Counsel Stack

Bluebook (online)
202 F.R.D. 94, 2001 WL 897367, Counsel Stack Legal Research, https://law.counselstack.com/opinion/karen-l-v-physicians-health-services-inc-ctd-2001.