A.H. v. Anthem Blue Cross

Background

A.H. filed the action individually and on behalf of B.H., a minor. A.H. alleged that Anthem Blue Cross wrongly denied coverage under a health benefits plan for B.H.’s treatment at blueFire Wilderness Therapy in Idaho from June through September 2020. The complaint described blueFire as providing sub-acute inpatient treatment for adolescents with mental-health, behavioral, or substance-abuse problems.

A.H. brought claims under the Employee Retirement Income Security Act (ERISA), alleging that Anthem violated the plan’s terms, and under the Mental Health Parity and Addiction Equity Act (Parity Act). Anthem moved to dismiss the complaint in its entirety under Federal Rule of Civil Procedure 12(b)(6), which allows dismissal when a complaint does not adequately state a legal claim.

ERISA Claim

The court considered the health plan because A.H.’s complaint referred to it and the plan formed the basis of the claims. The plan excluded residential accommodations for medical or behavioral-health conditions unless provided in specified facilities, and expressly listed wilderness camps among the exclusions. The exclusion stated that it did not apply to medically necessary treatment of severe mental illness or serious emotional disturbances of a child when coverage was required by state law.

Anthem argued that the plan excluded blueFire’s services. A.H. alleged that B.H.’s treatment was medically necessary and that B.H. qualified as a child with a serious emotional disturbance, but did not identify any California law requiring coverage for wilderness camps for children with severe mental illness or serious emotional disturbances. The court therefore found that A.H. had not plausibly alleged an entitlement to benefits under the plan and granted the motion to dismiss the ERISA claim.

Parity Act Claim

The Parity Act requires health plans to provide equal coverage for mental illnesses and physical illnesses. A.H. acknowledged that the plan’s wording applied its residential-accommodation limits, including the wilderness-camp exclusion, to both medical and behavioral-health conditions. A.H. nevertheless brought an as-applied challenge, alleging that Anthem applied the limits differently in practice.

A.H. alleged that Anthem applied the wilderness-camp exclusion exclusively to substance-use and mental-health benefits; paid claims for intermediate-level treatment of medical and surgical conditions; used more restrictive medical-necessity criteria for intermediate-level mental-health treatment; and offered comparable benefits for medical and surgical treatment at facilities excluded for mental-health treatment.

At the motion-to-dismiss stage, the court accepted the allegations as true for purposes of evaluating plausibility and found them sufficient to state a Parity Act claim. The court emphasized that Anthem disputed whether it actually applied the limits more strictly to mental-health benefits, but held that it could not resolve that factual dispute at this stage. The court therefore denied the motion to dismiss the Parity Act claim.

Disposition

The court granted in part and denied in part Anthem’s motion to dismiss: it granted the motion as to the ERISA claim and denied the motion as to the Parity Act claim. Because the court could not conclude that amendment would be futile, it allowed A.H. to file an amended complaint within 21 days of the order. The court also set a case-management conference for July 25, 2023, directed the parties to meet and confer, and required a revised joint case-management statement by July 18, 2023.