Doe v. United Behavioral Health

Background

Jane Doe proceeded under a pseudonym and represented her minor son, John Doe. She asserted two claims against United Behavioral Health and United Healthcare Services, Inc., collectively called United Health, for breach of fiduciary duty under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1132(a)(3). United Health served as the third-party and claims administrator for the Wipro Limited Health Benefit Plan. Wipro sponsored and funded the plan, controlled its terms, and retained the power to change or terminate it.

From 2017 through 2019, the plan covered autism but expressly excluded “Intensive Behavioral Therapies such as Applied Behavior Analysis for Autism Spectrum Disorders.” United Health denied expenses for these treatments. Effective January 1, 2020, the plan removed the exclusion and began covering the treatments. The court considered cross-motions for partial summary judgment, a procedure used when a party claims that no important factual dispute requires a trial and that it is entitled to judgment under the law.

The court also granted the related administrative motions to seal private health records, Docket Numbers 47, 52, and 57.

Issues and Analysis

United Health argued that both ERISA claims failed because it was not acting as a fiduciary when applying the exclusion. The court explained that fiduciary status depends on the specific activity at issue. A plan administrator may be a “functional fiduciary” when it exercises discretionary authority or control in administering a plan, even if the plan does not formally name it as a fiduciary. By contrast, purely ministerial administrative work generally does not create fiduciary responsibility.

The court found that United Health had authority to make benefits determinations under the Wipro Plan and exercised that authority when it denied Doe’s claim for her son’s treatment expenses. The court rejected United Health’s focus on the mechanical application of the exclusion, concluding that the relevant action was the broader benefits determination. It held that United Health’s denial of the benefits claim was sufficient to establish fiduciary status for Doe’s ERISA claims. The court therefore denied United Health’s motion for summary judgment on fiduciary status.

The court separately considered whether the exclusion violated the Mental Health Parity and Addiction Equity Act, which requires mental-health treatment limitations to be no more restrictive than the predominant limitations applied to substantially all medical and surgical benefits and prohibits separate treatment limitations applicable only to mental-health benefits.

The court held that the exclusion was a treatment limitation because it applied only to services for autism, which the opinion treated as a mental-health condition, and excluded a primary treatment for that condition. The plan contained no comparable medical or surgical exclusions. The court rejected United Health’s arguments that the plan could exclude ABA treatment because the Parity Act does not require plans to provide mental-health benefits, that the exclusion was not a treatment limitation because it was not expressed as a numerical limit, and that a regulatory exception for a permanent exclusion of all benefits for a condition applied. The court concluded that a plan may choose not to cover autism at all, but once it covers autism, its limitations on autism treatment must comply with parity requirements. The court held that the ABA/IBT exclusion violated the Parity Act.

Rulings and Disposition

The court granted Doe’s motion for partial summary judgment. It denied United Health’s motion for partial summary judgment on the fiduciary-status issue and denied United Health’s motion for partial summary judgment on the ground that the ABA/IBT exclusion complied with the Parity Act.

United Health had also moved for summary judgment concerning declaratory relief and standing. Doe withdrew her request for declaratory relief, while stating that she did not concede United Health’s arguments. In light of that withdrawal, the court granted United Health’s motion for summary judgment as to the withdrawn request for declaratory relief. Overall, the court granted in part and denied in part United Health’s motion for partial summary judgment.

The parties were ordered to meet and confer and file a status report and proposed schedule within 21 days. The order terminated Docket Numbers 47, 48, 52, 53, and 57.