Aetna and MLB Face ERISA Suit Over Denied Mental Health Claims

A Major League Baseball Players (MLB) Benefit Plan participant recently filed an ERISA lawsuit against Aetna Health and Life Insurance Co. (Aetna) and the MLB Benefits Plan. The suit challenges the denial of inpatient mental health treatment claims for the participant’s daughter.

MLB offers mental health benefits to employees and their beneficiaries, including inpatient and outpatient treatment of mental health conditions. In the complaint, the plaintiff alleges that California’s Mental Health Parity Act and the federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) require healthcare plans to provide medically necessary treatment for mental health conditions at a level equal to that for physical health conditions. The plaintiff also alleges that the defendants breached their fiduciary duty under ERISA in denying the claims for benefits.

Doctors diagnosed the plaintiff’s daughter with major depressive disorder, attention-deficit hyperactivity disorder, social communication disorder, an eating disorder, and avoidant personality disorder traits. Although the daughter received outpatient treatment, her condition continued to decline. Ultimately, at the recommendations of her treatment providers, she was admitted to Uinta Residential Treatment Center (“Uinta”) for inpatient mental health treatment.

Aetna denied the related claims for insurance coverage, stating that the treatment expenses were not covered because Uinta did not meet the definition of “physician” under the MLB benefits plan. Aetna further stated that the charges were unnecessary to diagnose, care for, or treat the daughter’s mental health conditions. The plaintiff appealed the denial of claims, but Aetna denied the appeal, claiming that Uinta was not recognized and approved by the appropriate hospital accreditation organization.

In the lawsuit, the plaintiff argued that Aetna should have covered the claims and was applying nonquantitative treatment limitations (NQTLs) on behavioral health benefits that did not apply to medical and surgical benefits. The plaintiff accused Aetna of imposing an accreditation requirement more applicable to medical or surgical treatment, as opposed to the accreditation requirement normally applicable to residential treatment programs, wilderness programs, and outdoor therapeutic programs. In imposing this accreditation requirement, the plaintiff argues Aetna applied NQTLs to behavioral health benefits that it did not apply to medical benefits.

The plaintiff is seeking payment of the denied treatment claims, prejudgment interest, and reasonable attorney’s fees and costs. The plaintiff also requests a court order barring Aetna from imposing accreditation requirements that constitute NQTLs and changing the appeals process so that it is fair for plan participants.

HBL has experience in all areas of benefits and employment law, offering a comprehensive solution to all your business benefits and HR/employment needs. We help ensure you are in compliance with the complex requirements of ERISA and the IRS code, as well as those laws that impact you and your employees. Together, we reduce your exposure to potential legal or financial penalties. Learn more by calling 470-571-1007.

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