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Benefits

Court Considers Exclusion for Wilderness Treatment Programs

EBIA  

EBIA  

Vorpahl v. Harvard Pilgrim Health Ins. Co., 2018 WL 3518511 (D. Mass. 2018)

Available at https://www.gpo.gov/fdsys/pkg/USCOURTS-mad-1_17-cv-10844/pdf/USCOURTS-mad-1_17-cv-10844-0.pdf

A court has declined to dismiss a lawsuit challenging an insurer’s denial of coverage for mental health services delivered in a wilderness program setting based on an exclusion in its policies. Participants in multiple employer-sponsored health plans filed a class action lawsuit against the insurer, claiming that the exclusion for services delivered in a wilderness program violated the federal mental health parity requirements and the Affordable Care Act (ACA). The insurer asked the court to dismiss the case, arguing that the exclusion was unambiguous and applied to medical and surgical benefits as well as mental health or substance use disorder benefits.

Explaining that the mental health parity requirements apply to treatment limitations based on facility type, the court considered whether the exclusion for wilderness programs applied equally to medical/surgical benefits and mental health or substance use disorder benefits. Although the insurer contended that the exclusion applied to both types of claims, the participants argued that the comparison needed to be made at the broader level of the equivalent inpatient treatment setting (such as rehabilitation hospitals and skilled nursing facilities). Concluding that the appropriate level of comparison would need to be determined as the case progresses, the court held that at this stage of the proceedings, it was sufficient for the participants to allege that a mental health treatment was categorically excluded while a corresponding medical treatment was not. However, the court dismissed the participants’ claim under the ACA provision prohibiting discrimination against a health care provider who is licensed to provide an otherwise covered service. The court ruled that the ACA does not require an insurer to contract with any provider willing to abide by the insurer’s conditions and cannot reasonably be construed to mandate that an insurer provide coverage for any and all services that a provider might be licensed to provide.

EBIA Comment: Other courts considering mental health parity cases have been equally vexed by the lack of a clear medical/surgical analog for inpatient mental health treatment, whether indoor or outdoor (see, e.g., our Checkpoint article). It will be interesting to see if this case proceeds to trial or settles. We note that the DOL recently stated that, to achieve the greatest impact, its mental health parity investigators are working with insurers to make “global corrections” of offending limitations. According to the DOL, these global changes have impacted hundreds of thousands of group health plans and millions of participants (see our Checkpoint article). For more information, see EBIA’s Group Health Plan Mandates manual at Sections IX.A (“What Is Mental Health Parity and Who Must Comply?”) and IX.E (“Mental Health Parity: Nonquantitative Treatment Limitations”). See also EBIA’s Self-Insured Health Plans manual at Section XIII.C (“Federally Mandated Benefits”) and EBIA’s Health Care Reform manual at Section XIII.D (“Nondiscrimination in Health Care Providers”).

Contributing Editors: EBIA Staff.

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