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Group Health Cooperative Autism Insurance Coverage Denial Class action

This lawsuit alleges that Group Health Cooperative unlawfully placed quantitative visit limits on mental health services that would be covered for a five year old plan beneficiary, in violation of the Mental Health Parity and Addiction Equity Act.

The Puget Sound Energy, Inc. Health Benefit Plan (PSE Plan) is an “employee welfare benefit plan” under ERISA, 29 U.S.C. § 1002(1), that provides both medical/surgical and mental health/substance use disorder benefits.  The health benefits of the PSE Plan are administered by a subsidiary of Washington based Group Health Cooperative (GHC).  GHC administers benefits for various ERISA governed self-funded employer-sponsored employee welfare benefits plans in multiple states.

In 2008, Congress enacted the Mental Health Parity and Addiction Equity Act, as an amendment to ERISA, (29 U.S.C.), which requires that if a plan covering more than 50 employees does provide mental health benefits, such coverage must be provided “at parity” with medical/surgical benefits.  The Parity Act requires that any treatment limitations on mental health benefits must also be applied to medical/surgical services and prohibits health plans from imposing special treatment limitations only on mental health benefits. Speech, occupational and physical therapy services to treat mental health conditions are considered “mental health services” under the terms of the PSE Plan, as well as under applicable state and federal law.  GHC administers claims for speech, occupational and physical therapy services to treat mental health conditions, such as Autism Spectrum Disorder (ASD).

Since 2014, M.R., the five-year old dependent of Washington state residents with PSE Plan coverage diagnosed with ASD, received diagnosis related speech and occupational therapy services.  She exhausted the quantitative visit limitations in her PSE Plan in both 2014 and 2015.  GHC denied coverage for these services under the Mental Health Benefit of the PSE Plan. If GHC provided coverage under the Mental Health Services benefit, the services would be covered without a visit limitation.

GHC determined that M.R.’s speech therapy and occupational therapy to treat ASD was limited under the Rehabilitation and/or Habilitation plan benefit. GHC’s denial of coverage of M.R.’s therapy services under the unlimited Mental Health Benefit resulted in both costs to M.R.’s parents and M.R. foregoing medically necessary treatment.  

On November 3, 2015, M.R. filed a class action suit (U.S. District Court Western District of Washington) against GHC on behalf of herself and other individuals who have received, required or are expected to require speech, occupational and physical therapies to treat a mental health condition seeking remedies under ERISA in which GHC applies quantitative visit limits on speech, occupational and physical therapies to treat mental health conditions.  The complaint seeks an order declaring the quantitative visit limitations imposed on speech, occupational and physical therapies to treat mental health conditions in GHC-administered plans are illegal and unenforceable, a permanent injunction prohibiting GHC from applying visit limitations on speech, occupational and physical therapies to treat mental health conditions, an order requiring GHC to provide accurate information concerning mental health coverage in class members’ plans, including coverage of speech, occupational and physical therapies to treat mental health conditions, damages related to GHC’s unjust enrichment, disgorgement, restitution and attorney’s fees.

Article Type: Lawsuit
Topic: Consumer
No case events.
Tags: Coverage Denial, Deceptive Insurance Practices, Your Health