Managed Care Litigation Update Volume 213: November 30, 2022

• Publication year: 2022

NEWSWORTHY

District court grants member's cross MSJ finding that OON targeted narrative language treatment of member diagnosed with ASD should be approved pursuant to plan term providing "where there is no network Provider available for the Covered Services, the Plan may authorize the network cost share amounts ... to apply to a claim...from an out-of-network Provider." Court determined that Plan's assertion that it had network providers who could provide the services was not supported by substantial evidence. Mark Zucca v. [], Community Insurance Company, USDC ND OH, No. 5:21-cv-1345-CEH, 2022 WL 17092803, (Doc. 40, filed Nov. 21, 2022).

District court grants preliminary approval of class action settlement, awarding families $5,000 to $88,875 associated with treatment at mental health residential programs, where plaintiffs allege administrator mislead families by citing "so-called exclusions in coverage denial letters rather than the true specific bases for the denial." Brent S., et al. v. Blue Cross and Blue Shield of Massachusetts, Inc., et al., USDC D MA, No. 1:17-cv-11569-ADB, (Doc. 240, filed Nov. 30, 2022).

Washington state appellate court affirms in part and reverses in part summary judgment in favor of plan affirming administrator's denial of residential treatment claim pursuant to a wilderness therapy exclusion. Court concluded that genuine issues of material fact existed as to whether the exclusion of wilderness programs is a separate treatment limitation that applies to only mental health services, precluding summary judgment in favor of plan. P.E.L., et al. v. Premera Blue Cross, WA Ct. App., No. 82800-2-I, 2022 WL 17087861, (filed Nov. 21, 2022).

RECENTLY FILED ACTIONS

United Healthcare Services, Inc. v. Teva Pharmaceuticals, et al., U.S.D.C. D. NJ, Doc. No. 2:22-cv-6643-EP-MAH, (filed Nov. 16, 2022). United seeks recovery of overpayments made on behalf of its Medicare beneficiaries for the prescription drug Copaxone, where it alleges an illegal scheme of waiving the cost-sharing amount in violation of the Anti-Kickback Statute.

Amrit Hans-Atchinson v. Aetna Life Insurance Company, U.S.D.C. M.D. FL, Doc. No. 6:22-cv-2166-WWB-DAB, (filed Nov. 21, 2022). Member seeks ERISA benefits from self-funded plan associated with inpatient treatment at NeuLife Rehabilitation in Florida to treat Guillian Barre Syndrome, Nerogenic Bladder and Pleural Effusion w/ PluerX Cath. After a period of coverage, further treatment was denied as not medically...