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Benefits

Another Court Dismisses Parity Claims for Wilderness Program Exclusion

EBIA  

EBIA  

 

A.G. v. Cmty. Ins. Co., 2019 WL 340471 (S.D. Ohio 2019)

Another court has rejected a challenge to a group health plan’s exclusion for mental health services provided in a wilderness setting. In this case, a plan participant’s daughter attended an outdoor behavioral therapy program where she was treated for mental health issues and a substance use disorder. The plan’s insurer denied the participant’s claim for the treatment, based on a plan provision excluding coverage for “wilderness camps.” After exhausting administrative appeals, the participant sued, seeking enforcement of the plan and alleging violation of the federal mental health parity requirements.

The participant argued that the plan’s exclusion of “wilderness camps” was ambiguous and could be understood to refer to experiential programs such as Outward Bound, rather than outdoor behavioral therapy programs such as his daughter’s program. The court noted, however, that outward bound programs were expressly excluded under the plan, and deferred to the insurer’s determination that the participant’s program was a wilderness camp subject to the plan’s exclusion. The participant further contended that the exclusion of wilderness camps violated the parity requirements because the plan covered medical and surgical services rendered at facilities such as rehabilitation hospitals and skilled nursing facilities. However, the court observed that the plan did cover services at residential treatment centers for both medical and mental health services—and it did not cover any services provided at wilderness camps. Thus, applying the standard outlined in Gallagher (see our Checkpoint article), the court ruled that the plan did not contain a discriminatory limitation on mental health services.

EBIA Comment: Lawsuits challenging wilderness therapy exclusions are steadily making their way through the courts. Health plan sponsors considering such exclusions should consult their legal advisors to ensure that the provisions are carefully drafted to comply with the parity rules. For more information, see EBIA’s Group Health Plan Mandates manual at Sections IX.A (“What Is Mental Health Parity and Who Must Comply?”), IX.E (“Mental Health Parity: Nonquantitative Treatment Limitations”), and IX.K (“Mental Health Parity: Table of Cases”). See also EBIA’s Self-Insured Health Plans manual at Sections XIII.C (“Federally Mandated Benefits”) and XIII.E (“Coverage Limitations and Exclusions”).

Contributing Editors: EBIA Staff.

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