Health Insurance Archives - Page 6 of 12

Have “Quack” Medical Reviewers Caused Denial of Your Long-Term Disability Claim? California Court of Appeal Berates Insurance Company for Controlling Medical Peer Reviews

During their Presidential election campaigns, Donald Trump and Hillary Clinton spotlighted for America flaws in our criminal justice system. They raised questions about whether the criminal probe into Ms. Clinton’s private email server was handled honestly or politically. Conservatives bitterly complained that FBI director Jim Comey’s recommendation not to prosecute Ms. Clinton was inconsistent with the FBI’s fact findings (that she carelessly mishandled classified emails) and influenced by the left-leaning Justice Department rather than justice. On the flip side, Liberals vehemently complained that on the eve of the election Director Comey made an unprecedented announcement that the FBI had reopened its criminal investigation into Ms. Clinton’s private emails, attempting to influence the election.

Whatever your political leanings are, most Americans would probably agree that politics has no business in a court of law, where a person’s freedom or livelihood is at stake. Lady Justice is supposed to be blind.

Like politics, “quack” physicians have inappropriately crept into our judicial process through the insurance industry. This has endangered blind justice for indigent policyholders. Wealthy life, health and disability insurers appear adept at getting a doctor to say just about anything for the right price. Some doctors are willing to sell the truth and abandon science for a steady stream of business from an insurance company. They have increasingly become willing to allow their high-paying insurance company clients to dictate what they can and cannot consider in reaching their professional medical opinions, often limiting them to a review of the insured’s medical records without the opportunity to examine or speak with the insured or his treating physicians. Some insurers seemingly have made this part of their business model to help them deny even legitimate claims made by their disabled or sick policyholders.

The California Court of Appeal recently criticized one such insurance company’s practice in the case of Nickerson v. Stonebridge Life Insurance Company, 5 Cal. App. 5th 1 (2016). While the bulk of the lengthy opinion focuses on the constitutionality of punitive damage awards – it held that a 10:1 ratio of punitive to compensatory damages in an insurance bad faith case passes muster – we have blogged on that topic and the Nickerson case before. See https://mslawllp.com/california-court-of-appeal-finds-that-a-101-ratio-between-punitive-damages-and-compensatory-damages/ (discussing Nickerson v. Stonebridge Life Insurance Company, 219 Cal. App. 4th 188 (2013)) and https://mslawllp.com/in-an-insurance-bad-faith-case-attorneys-fees-are-compensatory-damages-that-can-increase-a-punitive-damages-award/ (discussing Nickerson v. Stonebridge Life Insurance Company, 63 Cal. 4th 363 (2016). What is more interesting as it relates to ERISA and bad faith long-term disability insurance and health claims is that the Nickerson court berates the practice, systemic to the health and disability insurance industry, of hiring doctors to perform “pure paper reviews” of the insured’s medical records and, more accurately, of controlling the process to dictate results favorable to the insurance company.

The Nickerson case concerned a disabled veteran, Tom Nickerson, paralyzed from the chest down with no income other than a very small military pension. He bought a policy from Stonebridge providing coverage for hospital confinement. After suffering a broken leg from falling out of his wheelchair onto the asphalt, Nickerson was hospitalized for 109 days on the advice of his attending primary care physician. He submitted a claim to Stonebridge for his hospital stay. Stonebridge contended only 18 days was “Necessary Treatment” under its policy. On that basis, it denied him policy benefits for the rest of the time he was hospitalized. Nickerson sued Stonebridge for breach of the insurance contract and the implied covenant of good faith and fair dealing (i.e. “bad faith”) seeking his unpaid policy benefits, emotional distress, attorneys’ fees and punitive damages.

As health and disability insurers often to, Stonebridge had hired a medical consultant during the claim to review Nickerson’s medical records and render an opinion on whether 109 days of hospitalization was medically necessary. The insurance company’s doctor:

never spoke with the insured, Nickerson;
never spoke with Nickerson’s attending physicians; and
never examined Nickerson.

Based purely on a “paper review” of his medical records, Stonebridge’s doctor concluded that Nickerson should have been released from the hospital after eighteen days (which became the rationale for Stonebridge denying the claim).

Nickerson’s primary care physician disagreed and even wrote a three-paragraph letter to Stonebridge explaining in detail why hospitalization was required for 109 days, including that “the fracture was complicated by extensive swelling, infection, blistering, and muscle damage that required acute hospitalization, intravenous fluids and antibiotics, and full staff support including consultation with an orthopedic surgeon.” He further explained that because Nickerson was paraplegic and confined to a wheelchair, he could not have managed at home any earlier. Stonebridge never gave that information to its “paper reviewing” physician consultant and never asked him to speak with Nickerson’s treating doctor about his conflicting opinion. It withheld the obviously pertinent information and maintained its claim denial.

The court berated Stonebridge for what it found was a systemic company-wide practice: “Stonebridge’s practice was never to authorize peer reviewers to communicate with treating physicians, thus intentionally concealing material information from the claims’ functional decision-maker so as to limit the amount Stonebridge would have to pay out on its policies.” It held Stonebridge’s conduct in ignoring the opinion of the insured’s treating physician and withholding it from its peer reviewer essentially controlled the peer reviewer’s opinion and supported a finding that the insurer committed fraud warranting punitive damages, not just bad faith. The court held that the insurer’s conduct was “particularly reprehensible” warranting a higher constitutional ratio of compensatory to punitive damages. Finally, the court stated that, “Insurers may not ignore the opinion of treating physicians absent a showing the physician’s judgment is either ‘plainly unreasonable, or contrary to good medical practice.’ ”

Our take: Unfortunately, as the Nickerson case and our recent Presidential Election illustrate, Lady Justice is not always blind. It certainly isn’t for poor, out-of-work claimants fighting against billion-dollar life, health and long-term disability insurers with systemic corporate practices to the highest level of management aimed at denying even legitimate claims to line their own pockets with your hard-earned policy premiums. Justice is not blind for indigent claimants struggling against insurers’ handsomely paid “paper-reviewing” physicians complicit in the insurance industry’s often unfair claims handling practices.

If you have a long-term disability, life or health insurance claim, to equal the scales of justice, you need an experienced attorney to fight hard for you. At McKennon Law Group PC, our lawyers have decades of experience litigating these types of claims, both under ERISA and state insurance bad faith laws. Most of our lawyers previously spent years defending insurance companies against long-term disability, life and health insurance claims. That will give you a distinct advantage because our lawyers know how insurance companies operate and the arguments they are likely to raise from first-hand experience. We will review your claim free of charge. Your matter will be handled on a contingency basis, which means you pay nothing and we receive nothing unless you win a recovery by way of a settlement, claim reinstatement, verdict or award. Let us try to equal the scales of justice for you.

Health Insurance Law Update: Medical Providers Seeking Payment from Insurers Must File a Quantum Meruit Lawsuit Within Two Years of the First EOB

The most common complaint McKennon Law Group PC hears from medical providers is that insurers refuse to pay for the services provided to their insureds, even after the medical provider sought and obtained a pre-authorization from the insurer for the services provided to a patient. After submitting a bill to the insurance company, all too often, a physician or other medical professional receives an Explanation of Benefits (“EOB”) letter indicating that either the insurer will not pay the claim at all or it will only pay a fraction of the amount billed.

After receiving the EOB, medical providers typically utilize the insurer’s voluntary appeal process in an effort to secure full payment. That appeal process can drag on for years. In Vishva Dev, M.D., Inc. v. Blue Shield of California Life & Health Insurance Co., 2 Cal. App. 5th 1218 (2016), the California Court of Appeal ruled that the two-year statute of limitations for a quantum meruit claims begins to run when a doctor first receives an EOB letter even when the insurer offered an appeal and then delayed that process.

In Vishva, a physician filed a complaint asserting breach of contract and quantum meruit claims seeking larger payments for emergency care rendered to three different patients. A quantum meruit claim seeks payment of a reasonable sum of money for services rendered. In response, Blue Shield of California Life Insurance Company and Blue Shield of California (collectively, “Blue Shield”) filed a motion for summary judgment on the quantum meruit claim, on the grounds that the lawsuit was initiated more than two years after the physician received the initial EOB for each patient.

The physician opposed the motion for summary judgment on the grounds that the filing deadline was tolled during the lengthy appeal process in which he engaged at the invitation of Blue Shield, and did not start until the final EOB was issued. The trial court granted Blue Shield’s motion, and on appeal, that judgment was upheld on the grounds that the statute of limitations begins to run upon the first unequivocal denial of payment in writing, that is, the date of the original EOB.

The Court, citing numerous California Supreme Court rulings in homeowner’s insurance cases, also rejected the doctor’s argument that Blue Shield was estopped from raising that statute of limitation defense because the doctor reasonably relied on the appeals process to resolve any payment issues. The Court held that Blue Shield’s decision was established with the original EOB, and the appeal process was a mere “extension of a courtesy” that did not extend the statute of limitation. Finally, the Court advised that ruling otherwise would create a situation where an insurer may inadvertently extend the statute of limitations period by responding to a mere inquiry, which would contravene the public policy of encouraging insurers to respond to new, substantive facts.

The lesson from this ruling is clear, if you are a medical provider and intend to file a lawsuit against an insurance company seeking payment for services rendered to a patient, you must bring that lawsuit within two years of the date of the initial EOB, or you will have forfeited your ability to assert a quantum meruit claim.

Department of Labor Proposes New, Claimant-Friendly ERISA Regulations for Disability Insurance Claims

From time to time, the U.S. Department of Labor promulgates new regulations governing disability insurance benefit claims and health insurance benefit claims that are governed by the Employee Retirement Income Security Act of 1974, commonly referred to as ERISA. The regulations must be followed by plan administrators and claim administrators when reviewing disability insurance and health insurance benefit claims submitted by claimants. Recently, the Department of Labor proposed changes to the regulations governing long-term disability insurance benefit claims and short-term disability insurance benefit claims.

The proposed regulations, if approved, will benefit a claimant by providing greater access to information during the claims review process and requiring administrators to explain why their claim decision differs from State or Federal agencies that considered the claimant disabled and unable to return to work.

The stated purpose of the proposed new regulations, which can be found here, is to provide “procedural fairness” to claimants, as well as to adopt procedural protections and safeguards that are currently applicable to group health plans under the Affordable Care Act.

One of the changes is that a claims administrator would be required to “[a]llow a claimant to review the claim file and to present evidence and testimony as part of the disability benefit claims and appeals process.” In addition, the new regulations would:

Provide that, before an adverse determination on review is made, the plan administrator shall provide the claimant, free of charge, with any new or additional evidence considered, relied upon, or generated by the plan (or at the direction of the plan) in connection with the claim. Such evidence must be provided as soon as possible and sufficiently in advance of the date on which the notice of adverse determination on review is given, in order to give the claimant a reasonable opportunity to respond before that date.

Currently, until an adverse decision is made, the claims administrator is entitled to withhold from the claimant the entirety of the claim file. This allows the claim administrator to withhold opinions and reports regarding disability offered by paid physicians, who typically never examine the claimant, and any other evidence in the claim file. Refusing to allow the claimant access to the claim file while the claim is open forces the claimant to operate without a full and complete understanding of the opinions that the insurance company may be relying on in reviewing the claim. This makes it unnecessarily difficult for a claimant to know what information the insurer might deem important and sufficient to support the claim for disability insurance benefits.

Another important change is that denial letters must include “the basis for disagreeing with the views or decisions of any treating health care professionals or other payers of benefits who granted the claimant’s similar claims (including disability determinations by the SSA).” Recently, some district courts have ruled that a failure to distinguish contrary disability determinations, whether related to Workers’ Compensation Benefits, State disability insurance benefits or Social Security disability insurance benefits, will result in a reduction in the amount of discretion afforded to the administrator in abuse of discretion cases. This new regulation would codify this requirement nationwide and expand it, as it would force the administrator to explain in all claim denials why its opinion that a claimant is not disabled differs from conclusions reached by other entities after evaluating the same disabling conditions, medical evidence and job duties.

Finally, a failure by the administrator to follow these and other requirements will allow a claimant to consider the claim to be “deemed denied.” This would allow a claimant to be “deemed to have exhausted the administrative remedies under the Plan,” and proceed to litigation without the necessity of an appeal. However, the regulations also note that if a court finds the violation to be “de minimus,” then the matter would be remanded back to the plan administrator for further review. Given the risk of remand and resulting delay, a claimant might be reluctant to exercise this option.

As a whole, these regulations, if enacted, would greatly benefit claimants and should make it easier from them to understand the claim review process, the reasons for denial and easier to provide their administrators with documents to support their claims. Indeed, these proposed regulations would “give some teeth” to the requirement that insurers engage in a “meaningful dialogue” with the claimant.

Mistreated by Your Insurer? Insurers May Not Be Able to Hide Behind ERISA Preemption to Defeat Claims for Intentional Infliction of Emotional Distress

Insureds obligingly pay premiums on their life, health and disability insurance policies and dutifully provide updated information upon request by their insurers, but often do not enjoy the same courtesy when they file an insurance claim. In extreme cases, antagonistic insurers engage in a host of tactics, including appointing claims examiners who refuse to return phone calls, conducting intrusive surveillance, accusing insureds of filing false claims or inundating the insured’s employer and treating doctors with document demands—only to deny the insured’s claim. Astonished by this treatment, many insureds wonder if they can sue them for emotional distress damages. The short answer is yes—but there are hurdles.

California law imposes in every insurance contract a covenant of good faith and fair dealing, and a wrongful denial may be in “bad faith.” The bad faith claim potentially allows the insured to seek emotional distress damages. However, there may be another approach: sue the insurer for intentional infliction of emotional distress. To succeed on such a claim, insureds must establish: (1) extreme and outrageous conduct by the defendant with the intention of causing, or reckless disregard of the probability of causing, emotional distress; (2) the plaintiff’s severe or extreme emotional distress; and (3) actual and proximate causation of the emotional distress by the defendant’s outrageous conduct.

Policies governed by the Employee Retirement Income Security Act of 1974 (“ERISA”) present additional hurdles. First, Section 514(a) provides that the ERISA federal statutes “supersede[s] any and all State laws insofar as they may … relate to any employee benefit plan.” Second, ERISA does not contain a comparable statutory recourse for bad faith by an insurer. Accordingly, insurers routinely defeat emotional distress claims and insurance bad faith claims by asserting that ERISA preempts these state law claims, as such claims directly relate to the insured’s denial of benefits. However, a relatively unsung line of cases show that in cases where the insurer’s actions are so far removed from the claims handling function, an insured may escape ERISA preemption and seek damages typically available under California, but not federal, law.

In his recent Order, United States District Judge William Alsup ruled that ERISA does not preempt (or, in other words, defeat) an insured’s claim for intentional infliction of emotional distress in certain cases, even though the insurance policy is otherwise governed by ERISA. Daie v. The Reed Grp., Ltd., No. C 15-03813 WHA, 2015 WL 6954915 (N.D. Cal. Nov. 10, 2015). After Aetna denied his claim for disability benefits and appeal under an employer-sponsored plan, Plaintiff filed suit asserting only one cause of action for intentional infliction of emotional distress. Plaintiff’s complaint alleged, among other things, that Defendants accused Plaintiff of lying about and exaggerating his condition, pressured him to take experimental medications and forced him to undergo rigorous medical examinations without considering the results.

Defendants moved to dismiss the claim based on federal preemption under ERISA. Judge Alsup denied the motion, explaining that ERISA completely preempts a state-law only if: (1) an individual at some point could have brought the claim under ERISA Section 502(a)(1)(B), which allows an ERISA “participant or beneficiary” to bring a civil action to recover benefits due, enforce his rights, or clarify his rights under the plan and (2) no other independent legal duty is implicated. Here, neither prong was satisfied. First, Plaintiff’s claim hinged on the Defendants’ harassing and oppressive conduct unrelated to the claims handling function. Second, Defendants had a duty not to engage in tortious conduct, which was independent of the Defendants’ duties under ERISA. Judge Alsup further noted that absent the denial of benefits, Daie would still have a claim for intentional infliction of emotional distress.

Other cases offer insight as to what type of actions by insurers may survive ERISA preemption. One example involves an insurance company who engaged in surveillance tactics, including falsely impersonating a bank lender to obtain personal information about a plaintiff (Dishman v. Unum Life Insurance Co. of America, 269 F.3d 974 (9th Cir. 2001)). Sarkisyan v. CIGNA Healthcare of California, Inc., 613 F. Supp. 2d 1199, 1208-09 (C.D. Cal. 2009) distinguishes what claims may, or may not be, preempted. In Sarkisyan, CIGNA denied authorization for a liver transplant for Plaintiff’s daughter, upheld the denial, and the girl passed away days later. The grief-stricken parents brought suit alleging several causes of action, including intentional infliction of emotional distress. CIGNA removed the case to federal court, then filed a motion to dismiss, contending Plaintiffs’ claims were expressly preempted by ERISA. The District Court ruled that Plaintiff’s state law claims for intentional infliction of emotional distress based on wrongful denial of coverage under their CIGNA health insurance plan related directly to CIGNA’s denial of benefits, and thus were preempted by ERISA. However, Plaintiffs’ state law claim for intentional infliction of emotional distress based on the verbal abuse, heckling, and “lewd hand gesture” by CIGNA employees was not preempted, because the claim was based on events occurring after the coverage decision, and thus did not directly relate to the claim decision.

These cases demonstrate that where a plaintiff’s allegations of intentional infliction of emotional distress clearly implicate an independent legal duty owed by the insurer, distinct from actions directly related to the claim for benefits, ERISA preemption does not defeat the claim. Indeed, these holdings are consistent with public policy concerns and serve as a disincentive to insurers who mistreat their insureds, or risk liability in the form of extra-contractual damages for intentional infliction of emotional distress.

CBS’ 60 Minutes Segment “Denied” Highlights Insurers’ Wrongful Denial of Mental Health Claims

On Sunday December 14, 2014, CBS’ 60 Minutes program contained a segment entitled “Denied” which highlights that insurers routinely deny, based on lack of medical necessity, treatment for patients with mental illnesses, especially those for long-term in-patient care at mental health facilities. This segment was an indictment of health insurance companies’ actions (especially Anthem Blue Cross) to deny legitimate claims for such care, sometimes with tragic results. According to 60 Minutes, “we found that the vast majority of claims are routine but the insurance industry aggressively reviews the cost of chronic cases. Long-term care is often denied by insurance company doctors who never see the patient. As a result, some seriously ill patients are discharged from hospitals over the objections of psychiatrists who warn that someone may die.”

As we see all too often, insurers rely on their non-independent physician consultants, who are paid handsomely for their opinions, who render decisions favoring the insurers’ attempts to deny legitimate claims. These physician consultants do not see or physically examine the insureds, but rather perform a “peer review” or “paper review” based on a review of medical records and other information. These physicians typically attempt to contact the insured’s treating physicians to ask questions, but in reality use these “attempted” phone calls as a pretext to opinions against the insured’s interest (i.e., that the insured does not need additional mental health care) so that the insurer can deny these claims. This is very often done without giving the treating physician adequate time for a response. This is exactly what the 60 Minutes segment found.

This problem is so prevalent that when McKennon Law Group clients hire us to represent them to handle ERISA or non-ERISA insurance claim correspondence and appeals, we now instruct insurers that if they wish to contact our clients’ treating physicians, any communications between the insurer’s consulting physician and the treating physicians must be in writing, include only those questions that are pertinent to the claim and include a reasonable time to allow the treating physicians to adequately respond to the questions. This allows the treating physicians the time necessary to adequately respond to the questions in writing, with the benefit of allowing them to review the most recent medical records. All too often we have seen a scenario in which an insurer’s consulting physician makes a “cold call” to an insured’s treating physician without an appointment to speak to him or her in the midst of a busy practice schedule. This creates several problems. First, the treating physician may not be able to immediately take the call because he or she is treating patients. As a result, the insurer’s physician notes that the treating physician did not take his call and an implication is raised that the insured’s physician does not support the claim. Second, even if the treating physician is able to take the call, he or she may not be prepared to thoroughly discuss the claim or the restrictions and limitations without a review of his or her records. If pressed for answers regarding the date of last examination or clinical findings, the treating physician may, understandably, not be able to give complete or accurate answers. Of course, this does not stop the physician consultants and insurance companies from arguing that the treating physicians do not support the insured’s claim. Communication in writing alleviates these problems.

The real problem is that (as the CBS segment notes) doctors hired by the insurance companies are paid for each medical review they complete, and in many cases, the so-called independent physician consultants conduct hundreds of reviews per year for these insurers. They are thus economically motivated to render opinions that allow insurers to deny legitimate health insurance claims because they want repeat business.

California Insurance Commissioner Dave Jones commented on the 60 Minutes segment, stating that:

60 Minutes featured a story last night about Anthem Blue Cross’ denial of coverage for patients needing mental health treatment. “I am very pleased to see that 60 Minutes has brought national attention to our disputes with Anthem Blue Cross over their denial of coverage for mental health treatment,” said California Insurance Commissioner Dave Jones. “Medically necessary mental health treatment, including residential mental health treatment, is required to be covered under mental health parity laws.”

(Calif. Dept of Insurance, “Insurance Commissioner responds to 60 Minutes story about insurer denials of coverage for mental health treatment,” December 15, 2014)

State and federal mental health parity laws are in place to prevent health insurers from denying coverage for mental health care. California Insurance Code section 10144.5 requires health insurance policies to cover diagnosis and medically necessary treatment of severe mental illnesses for patients of all ages.

One issue not mentioned in the 60 Minutes segment is that insureds typically have a review or appeal process available to them. In order to navigate this complex area of the law, it is advisable that they seek out the advice of experienced attorneys in this area of the law when they are faced with insurance claim denials.

Recent Federal Cases Applying the State and Federal Mental Health Parity Acts: What Do They All Mean?

The Federal Mental Health Parity and Addiction Equity Act (“MH Parity Act”) requires, at a minimum, that the financial requirements and treatment limitations for mental health benefits set by group health plans and health insurance carriers be no more restrictive than those provided for non-mental health medical benefits. The MH Parity Act was originally signed into law by President Bill Clinton in 1996 and amended the Employee Retirement Income Security Act (ERISA) and Public Health Service Act and Internal Revenue Code in 2008. Now, the MH Parity Act is at issue in an increasing number of cases and has been addressed several times by the federal courts in the Ninth Circuit Court of Appeals.

Daniel F. v. Blue Shield of California, U.S. Dist. LEXIS 111643 (N.D. Cal. Aug. 11, 2014) began with two parents seeking coverage for residential treatment of their minor son’s mental health condition under their Blue Shield health insurance plan, governed by ERISA. Blue Shield denied the claim, stating its policy excluded coverage of residential treatment services for severe mental health conditions. Plaintiffs brought suit alleging violation of the insurance contract and a claim for declaratory and injunctive relief, but the court granted summary judgment for Blue Shield. During the appeal of this case, the Ninth Circuit issued Harlick v. Blue Shield of California, 686 F.3d 699 (9th Cir. 2012) holding the MH Parity Act requires health plans to provide coverage for all medically necessary treatment for severe mental illness, subject to the same financial terms as imposed on coverage for physical illnesses. Plaintiffs sought to maintain a class action against Blue Shield on behalf of participants covered under Blue Shield health insurance plans, governed by ERISA, whose claims for residential treatment of mental health claims were denied. However, the court explained class certification would require individualized discovery and proof, inquiries into medical necessity and whether individual mental health conditions and treatment were covered under the California Parity Act and additional difficulties with determining damages. Ultimately, the court held Plaintiffs failed to articulate a definition of an ascertainable class, and denied the motion for class certification.

Brazil v. OPM, 2014 U.S. Dist. LEXIS 44856 (N.D. Cal. Mar. 28, 2014) involved a plaintiff who received medically necessary mental health treatment at a residential facility, but her federal health insurance plan excluded coverage for residential treatment. The Plaintiff exhausted all administrative remedies and brought suit against the Office of Personnel Management (“OPM”) in federal court. The court held the plaintiff cannot recover under the MH Parity Act because the OPM has sovereign immunity, and Congress did not consent to be sued under the MH Parity Act. Brazil demonstrates the MH Parity Act did not apply to federal insurance plans.

A.F. v. Providence Health Plan, 2014 U.S. Dist. LEXIS 109507 (D. Or. Aug. 8, 2014) involved plaintiffs who sought an order enjoining the insurer, Providence Health Plan, from excluding applied behavior analysis therapy for participants diagnosed with autism spectrum disorders. The court granted the plaintiffs’ partial motion for summary judgment holding Providence’s “Developmental Disability Exclusion,” which excluded coverage for services relating to “developmental disabilities, developmental delays or learning disabilities” but not medical or surgical conditions, constituted a violation of the MH Parity Act and the Oregon Mental Health Parity Act.

R.H. v. Premera Blue Cross, 2014 U.S. Dist. LEXIS 108503 (W.D. Wash. Aug. 6, 2014) involved a class action suit in which plaintiffs alleged Premera Blue Cross, imposed treatment limitations on applied behavior analysis and neurodevelopmental therapy when similar limitations were not applied to medical benefits in violation of Washington’s Mental Health Parity Act. Premera agreed to a settlement in which it would remove the limitations and establish a $3.5 million settlement fund to reimburse plaintiffs who were denied services under the limitation. The court approved the unopposed class settlement as fair, reasonable, and adequate.

The trend of cases reveal practical considerations some insureds may encounter in bringing suit against their health insurance company if benefits are small, and additional difficulties establishing a class action suit. However, these decisions reflect the Ninth Circuit Court’s interpretation of the MH Parity Act, its willingness to hold health insurance carriers responsible for violations and ensure that insureds who have health insurance coverage have a viable claims for violations of the MH Parity Act.

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