S. v. Premera Blue Cross

CourtDistrict Court, D. Utah
DecidedApril 7, 2020
Docket2:19-cv-00199
StatusUnknown

This text of S. v. Premera Blue Cross (S. v. Premera Blue Cross) is published on Counsel Stack Legal Research, covering District Court, D. Utah primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
S. v. Premera Blue Cross, (D. Utah 2020).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF UTAH

M.S., L.S., and C.J.S., MEMORANDUM DECISION AND ORDER DENYING MOTION FOR Plaintiffs, JUDGMENT ON THE PLEADINGS

v. Case No. 2:19-cv-00199 PREMERA BLUE CROSS, MICROSOFT CORPORATION, and the MICROSOFT Chief Judge Robert J. Shelby CORPORATION WELFARE PLAN, Magistrate Judge Cecilia M. Romero Defendants.

This action concerns a denial of benefits under the Employee Retirement Income Security Act (ERISA).1 Plaintiffs M.S., L.S., and C.J.S. bring this action against Defendants Premera Blue Cross (Premera), Microsoft Corporation (Microsoft), and Microsoft Corporation Welfare Plan (the Plan) claiming—among other things—Defendants violated the Mental Health Parity and Addiction Equity Act (Parity Act).2 Defendants filed a joint Motion for Judgment on the Pleadings, seeking dismissal of Plaintiffs’ Parity Act claim.3 For the reasons explained below, Defendants’ Motion is DENIED.

1 29 U.S.C. § 1001 et seq. 2 See dkt. 2. 3 See dkt. 25. Defendants do not seek judgment on the pleadings with respect to Plaintiffs’ remaining claims. BACKGROUND4 The S. Family lives in King County, Washington.5 M.S. and L.S. are C.J.S.’s parents.6 The Plan is a self-funded employee welfare benefits plan under ERISA.7 At all relevant times, Microsoft was the Plan’s designated administrator and Premera served as the Plan’s third-party claims administrator.8 M.S. was a participant in the Plan and C.J.S. was a beneficiary of the Plan.9 On August 31, 2017, C.J.S. was admitted to Daniels Academy, a residential treatment

facility in Utah that specializes in treating individuals on the autism spectrum.10 On September 8, 2017, Premera sent Plaintiffs a letter denying payment for C.J.S.’s treatment at Daniels Academy, stating it had determined such treatment was considered “not medically necessary.”11 Specifically, Premera noted that C.J.S. failed to meet a number of its criteria for mental health residential treatment, such as “[C.J.S.] cannot be managed safely in the community because, for the last 6 months or longer, [C.J.S.] ha[s] been repeatedly hurting [themselves] [or] hurting others” and “[C.J.S.’s] support system is . . . not able to . . . keep [C.J.S.] safe.”12

4 When reviewing a motion for judgment on the pleadings, the courts “accept[s] the well-pleaded allegations of the complaint as true and construe[s] them in the light most favorable to the plaintiff.” Ramirez v. Dep’t of Corr., Colo., 222 F.3d 1238, 1240 (10th Cir. 2000). 5 Dkt. 2 ¶ 1. 6 Dkt. 2 ¶ 1. 7 Dkt. 2 ¶ 5. 8 Dkt. 2 ¶¶ 2, 4. 9 Dkt. 2 ¶ 5. 10 Dkt. 2 ¶ 6. 11 Dkt. 2 ¶ 19. 12 Dkt. 2 ¶ 19. On February 27, 2018, M.S. and L.S. submitted a level one appeal of the denial of benefits for C.J.S.’s treatment at Daniels Academy.13 In their appeal letter, they wrote that the criteria Premera utilized “incorrectly conflated acute and subacute levels of care” and that residential treatment is “designed for individuals who need[] a subacute level of care and [is] not appropriate for individuals experiencing acute symptomology.”14 They also wrote that Premera violated the Parity Act when it denied benefits for C.J.S.’s treatment because “Premera d[oes] not impose requirements such as acute symptomology on analogous intermediate levels of care

such as skilled nursing facilities.”15 On March 26, 2018, Premera sent Plaintiffs a letter stating it would still deny coverage for C.J.S.’s treatment.16 The letter included an opinion written by an external reviewer who opined that C.J.S.’s treatment was not medically necessary.17 The reviewer concluded that, “according to the terms of the Plan and [Premera’s] criteria,” C.J.S. did not qualify for residential treatment and instead could be safely and effectively treated at a lower level of care.18 On July 10, 2018, M.S. and L.S. requested the denial of C.J.S.’s treatment be reviewed by an external review agency.19 In that letter, they reiterated their concerns about the criteria Premera utilized to evaluate C.J.S.’s claim.20

13 Dkt. 2 ¶ 20. 14 Dkt. 2 ¶ 21. 15 Dkt. 2 ¶ 25. 16 See dkt. 2 ¶¶ 29–30. 17 Dkt. 2 ¶ 30. 18 Dkt. 2 ¶ 31. 19 Dkt. 2 ¶ 35. 20 Dkt. 2 ¶ 35. On July 27, 2018, an external review agency upheld the denial of benefits, concluding C.J.S.’s treatment was not medically necessary.21 Having exhausted their pre-litigation appeal obligations under ERISA and the Plan, Plaintiffs filed a Complaint with this court on March 20, 2019.22 Relevant here, Plaintiffs’ Complaint alleges causes of action for: (1) improper denial of benefits and (2) violation of the Parity Act.23 On November 11, 2019, Defendants filed a Joint Motion for Judgment on the Pleadings, seeking dismissal of Plaintiffs’ Parity Act claim.24

LEGAL STANDARD “After the pleadings are closed—but early enough not to delay trial—a party may move for judgment on the pleadings.”25 The court reviews a Rule 12(c) motion seeking dismissal of a claim under the same standard it reviews a Rule 12(b)(6) motion for failure to state a claim upon which relief can be granted.26 To survive a Rule 12(b)(6) motion to dismiss, “a complaint must contain sufficient factual matter, accepted as true, to state a claim to relief that is plausible on its face.”27 A claim is plausible on its face “when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged.”28 When evaluating

a motion to dismiss, the court “accept[s] all well-pleaded facts [in the complaint] as true and

21 Dkt. 2 ¶ 41. 22 Dkt. 2. 23 Dkt. 2 ¶¶ 49–56. The Complaint also alleges a cause of action for failure to furnish certain Plan documents, dkt. 2 ¶¶ 57–60. Defendants have not moved to dismiss that claim. 24 Dkt. 25. 25 Fed. R. Civ. P. 12(c). 26 Ward v. Utah, 321 F.3d 1263, 1266 (10th Cir. 2003). 27 Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (citation omitted). 28 Id. view[s] them in the light most favorable to the plaintiff.”29 However, the court will not accept as true “[t]hreadbare recitals of the elements of a cause of action, supported by mere conclusory statements.”30 The reviewing court is required to “draw on its judicial experience and common sense” to evaluate whether the well-pled facts state a plausible claim for relief.31 “Though a complaint need not provide detailed factual allegations, it must give just enough factual detail to provide [defendants] fair notice of what the . . . claim is and the grounds upon which it rests.”32 ANALYSIS

I. PARITY ACT OVERVIEW Congress enacted the Mental Health Parity Act (MHPA) in 1996, requiring group health plans to impose the same “aggregate lifetime and annual dollar limits for mental health benefits and medical and surgical benefits.”33 Congress amended the MHPA in 2008, when it passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.34 As amended, the Parity Act is designed “to end discrimination in the provision of insurance coverage for mental health and substance use disorders as compared to coverage for medical and surgical conditions in employer-sponsored group health plans.”35 In general terms, a health plan that provides medical and surgical benefits as well as mental health or substance abuse benefits “cannot impose more restrictions on the latter than it imposes on the former.”36

29 Jordan-Arapahoe, LLP v. Bd. of Cty.

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S. v. Premera Blue Cross, Counsel Stack Legal Research, https://law.counselstack.com/opinion/s-v-premera-blue-cross-utd-2020.