L.L. v. Anthem Blue Cross Life and Health Ins., 2023 WL 2480053 (D. Utah 2023)
A group health plan participant sued the plan, its claims administrator, and her employer (as plan administrator) after the plan denied coverage for wilderness therapy for her daughter’s mental health issues and substance use disorder. The denial letter stated that the treatment was excluded under the plan as investigational and not medically necessary because there was not enough proof that wilderness therapy improves health outcomes. After multiple levels of external review, the participant sued under the Mental Health Parity and Addiction Equity Act (MHPAEA), arguing that the plan impermissibly excluded wilderness programs for mental health/substance use disorder (MH/SUD) benefits but not for analogous medical/surgical benefits. She also sought statutory penalties under ERISA for the claims administrator’s failure to produce requested plan documents. The employer and claims administrator asserted that the exclusion applied equally to all wilderness programs, whether intended to treat medical conditions or behavioral health disorders. And they sought dismissal of the claim for statutory penalties, arguing that only the designated plan administrator (here, the employer) can be held liable for statutory penalties, and the participant did not allege that she had requested documents from the employer.
Noting that a successful MHPAEA claim requires a participant to plead facts showing a disparity in the plan’s treatment of MH/SUD and medical/surgical benefits, the court concluded that the participant’s allegation was unsupported and contradicted plan language expressly applying the exclusion to both types of benefits. The court also dismissed the claim for statutory penalties, holding that neither the claims administrator nor the employer could be held liable where the participant made the document request to the claims administrator rather than to the employer as the designated plan administrator. A separate claim for recovery of benefits under ERISA (based on the participant’s arguments and evidence that wilderness programs are not investigational) was not contested and was allowed to proceed.
EBIA Comment: Wilderness therapy exclusions are a frequent target of litigation, with courts reaching different conclusions based on specific allegations (see, e.g., our Checkpoint article). Plan sponsors, administrators, and their advisors should pay particular attention to such exclusions, ensuring that they do not run afoul of the MHPAEA. In addition, exclusions of this type are considered nonquantitative treatment limitations (NQTLs) that must be addressed in a plan’s required NQTL comparative analyses (see our Checkpoint Question of the Week). For more information, see EBIA’s Group Health Plan Mandates manual at Sections IX.E (“Nonquantitative Treatment Limitations”) and IX.K (“Mental Health Parity: Table of Cases”). See also EBIA’s Self-Insured Health Plans manual at Section XIII.C.2 (“MHPA and MHPAEA: Mental Health Parity”).
Contributing Editors: EBIA Staff.