Court Allows Mental Health Parity Claim Challenging Insurer’s Treatment Limitation for Eating Disorders

A health plan participant sued the plan’s insurer to recover benefits for treatment she had received for an eating disorder, claiming that the insurer violated the federal mental health parity requirements by imposing arbitrary reimbursement penalties on psychotherapy provided by psychologists and masters’ level counselors rather than by physicians. The insurer asked the court to dismiss the claim, arguing that the individual had not adequately alleged that its reimbursement processes for these behavioral health services were more stringent than processes used for comparable medical and surgical services.

The court rejected the insurer’s motion to dismiss the mental health parity claim. It explained that the insurer’s restriction based on the provider’s specialty was a treatment limitation subject to the mental health parity requirements. Pointing out that the insurer did not impose similar treatment limitations on medical and surgical benefits, the court held that the participant had adequately alleged at this stage of the proceedings that the restriction was a separate treatment limitation applied only to mental health or substance use disorder benefits.

EBIA Comment: Health plan participants have ample guidance to lean on in bringing a federal mental health parity lawsuit based on a limitation on eating disorder benefits. The 21st Century Cures Act specifically provides that coverage for eating disorder benefits is subject to the parity requirements (see our Checkpoint article). Furthermore, agency guidance reiterates that eating disorders are mental health conditions and, therefore, treatment of an eating disorder is a mental health benefit (see, e.g., our Checkpoint article). And recent cases have addressed the application of mental health parity to eating disorder benefits, including nutritional counseling (see our Checkpoint article) and residential treatment (see our Checkpoint article). For more information, see EBIA’s Group Health Plan Mandates manual at Section IX.E (“Mental Health Parity: Nonquantitative Treatment Limitations”). See also EBIA’s Self-Insured Health Plans manual at Section XIII.E (“Coverage Limitations and Exclusions”).

Contributing Editors: EBIA Staff.