J.L. attended Wingate Wilderness Therapy for medical treatment and care. Wingate is a licensed treatment facility in Utah that provides sub-acute inpatient wilderness treatment to adolescents with mental health, behavioral, and/or substance abuse problems. J.L.’s health insurance provider, Anthem, denied coverage for J.L.’s treatment because the treatment was deemed investigational and not medical necessary. Anthem denied coverage because there was no proof or not enough proof that wilderness therapy improves health outcomes.
J.L.’s parent (Plaintiff) appealed the denial of the benefits stating various objections. Anthem sent the claim to an external reviewer, who recommended upholding the denial of the claim, and ultimately, Anthem continued to deny the claim. After Plaintiff exhausted his pre-litigation appeal rights under the terms of the health plan, he sued Anthem, its claims administrator, and his employer (as plan administrator).
The United States District Court reviewed Plaintiffs’ Mental Health Parity and Additional Equity Act (Parity Act) claim. The Parity Act provides that treatment limitations on mental health and substance use disorders should be no more restrictive than limitations applied to substantially all medical and surgical conditions. (The Parity Act applies to health plans with 51 or more employees of private companies or governmental employers.) To prove a disparity, Plaintiff was required to analyze the limitations Anthem placed on medical or surgical treatment and compare them to the limitations placed on analogous residential mental health treatment.
Plaintiff claimed the Anthem health plan did not exclude wilderness programs for any medical and surgical benefits but did for mental health and substance use disorder benefits. However, the court found that Anthem’s policy excluded wilderness programs for all types of benefits, regardless of whether they treated medical or behavioral health conditions. Additionally, the health plan required that all covered services be medically necessary and not investigational. The health plan defined investigational services as those that are not widely accepted as proven and effective within the medical community.
The court determined that Plaintiff failed to offer any factual allegations to support the conclusion that Anthem imposed a different standard when assessing whether mental health benefits are investigational and when analogous medical or surgical benefits are investigational. Further the court found that Plaintiff’s belief that Anthem’s external experts were wrong when they determined wilderness programs are investigational was not sufficient to state a claim. The court dismissed the Parity Act claim.
L.L. v. Anthem Blue Cross Life and Health Insurance, DLA, 2023 WL 2480053 (D. Utah, 2023).