Aetna, MLB hit with ERISA suit over denied mental health coverage

Aetna Health and Life Insurance Co. and Major League Baseball Players Benefit Plan were hit with an ERISA lawsuit, challenging mental health claims that were denied by his health insurance benefits.

This complaint was first surfaced by Law.com Radar.

The court action was filed July 28 in the U.S. District Court for the Northern District of California by DL Law Group on behalf of a plaintiff identified as “Chris C.”

The suit challenges the denial of insurance coverage for inpatient mental health treatment provided to the plaintiff’s daughter, claiming the defendants violated the agreement of the benefits plan in denying to cover the treatment.

Related: Court sides with Aetna in lawsuits over prescription drug coverage

According to the complaint, Chris C. participated in the Major League Baseball Players Benefit Plan, which is the insurance plan that offers mental health benefits to employees and their beneficiaries, including inpatient and outpatient treatment of mental health conditions, the complaint said.

The complaint alleges that California’s Mental Health Parity Act, Health & Safety Code Section 1374.72, as well as the Federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), specifically require health care plans to provide medically necessary diagnosis, care and treatment for the treatment of specified mental health illness at a level equal to the provision of benefits for physical illnesses.

Chris C.’s daughter, A.C., was diagnosed with major depressive disorder, attention-deficit hyperactivity disorder, social communication disorder, an eating disorder, and avoidant personality disorder traits. Despite receiving outpatient therapy, her condition continued to deteriorate, the complaint said.

She was ultimately admitted to Uinta Academy Residential Treatment Center, a specialized treatment facility that provides inpatient treatment for mental illnesses, at the recommendation of her treatment providers. Chris C. argues that his insurance should have covered his daughter’s care.

Aetna, however, denied the claims for mental health benefits pursuant to the terms of the plan for his daughter’s treatment, stating the “expenses are not covered because this provider does not meet the plan definition of a ‘physician.’”

Further, Aetna claimed that the plan only covered “charges we find as needed to diagnose, care, or treat the condition,” and that based on the materials sent, it didn’t cover it, according to the complaint.

Chris C. appealed the plan’s denial of A.C.’s claims, however, the plan denied the appeal, claiming it “was denied because Uinta is not recognized and approved by the Joint Commission of Accreditation of Hospitals or the Council on Accreditation of the state where the service is rendered.”

According to the complaint, in denying the claim the defendants used nonquantitative treatment limitations (NQTLs) on behavioral health benefits that don’t generally apply to medical and surgical benefits, and that in denying the claim, the defendants “imposed an accreditation requirement that does not apply to outdoor behavioral health treatment.”

“By imposing accreditation requirements that are more applicable to medical/surgical treatment, while ignoring the accreditation requirements that apply to residential treatment programs, wilderness programs, and outdoor therapeutic programs, Defendants effectively limit coverage for such treatment,” the complaint said.

“The NQTLs Defendants used in denying Plaintiff’s claims are unfair and biased against approving claims for mental health treatment such as are at issue herein, and are prohibited under the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).”

Chris C. brings claims for recovery of benefits due under an ERISA Benefit Plan, violation of MHPAEA under 29 U.S.C. §1132(a)(3), and breach of fiduciary duty under ERISA Section 502(a)(3), 29 U.S.C. Section 1132(a)(3).

“Health insurance is meant to help people when they are the most vulnerable, and Aetna violated this most basic, and most important trust. The company’s use of boilerplate denials based on illegal technicalities isn’t just wrong, it’s unconscionable,” said Chris C.’s attorney, David Lilienstein of DL Law Group, in San Francisco.

In terms of relief, Chris C. seeks the defendants to pay the mental health benefits due and the award of reasonable attorney fees and costs.

The lawsuit requests a court to order defendants “to pay mental health benefits due, together with prejudgment interest on each and every such benefit payment through the date of judgment at the rate of 9% compounded.”

Further, Chris C. requested the court order the defendant to stop imposing accreditation requirements constitute NQTLs, as well as ordering that the defendants change procedures so that the appeals process becomes fair for plan participants, “that each fiduciary found liable for breaching his/her/its duties to disgorge any profits made through the denial of medically necessary claims through the use of inconsistent care guidelines,” and that the defendants reevaluate Chris C.’s claims in compliance with California’s Mental Health Parity Act, Health & Safety Code §1374.72 and Insurance Code § 10144.5, and MHPAEA.

The complaint also requested that Aetna be removed as a plan fiduciary.

Counsel have not yet appeared for the defendants.