Managed Care Litigation Update Volume 221: March 31, 2023

• Publication year: 2023

NEWSWORTHY

District court dismisses OON provider's ERISA claim for alleged under reimbursement of chiropractic health benefits, finding the provider lacked standing to bring an ERISA claim on behalf of the patient due to the plan's anti-assignment provision, notwithstanding assignment of benefits and a designation of authorized representative. Advanced Physical Medicine of Yorkville, LTD. v. Cigna Health and Life Ins. Co., et al., USDC N.D. IL, No. 1:22-cv-2991, 2023 WL 2631725 (Doc. 37, filed Mar. 24, 2023). Previously reported at MCLU Vol. 202.

District court dismisses claims of proposed class of members seeking coverage for hearing loss treatment, finding that patients' claims under the ACA § 1557, and state law, failed as the patients failed to allege plan provisions that were discriminatory based on an alleged disability. E.S., et al. v. Regence Blueshield, et al., USDC WD WA, No. 2:17-cv-1609-RAJ (Doc. 53, filed Mar. 16, 2023).

District court grants union health fund's motion to dismiss claims of OON provider seeking reimbursement for COVID testing, finding that provider's claim under ERISA failed due to anti-assignment clause in the plans. Murphy Medical Associates, LLC v. 1199SEIU National Benefit Fund, USDC D CT., No. 3:22-CV-64-KAD, 2023 WL 2631811 (Doc. 48, filed Mar. 24, 2023).

District court grants MSJ on patient's claims seeking coverage of residential mental health treatment, finding the plan's medical necessity determinations were neither arbitrary nor capricious and the plan's mental health limitations were not more restrictive than limitations placed on medical surgical benefits. M.Z. and N.H. v. [BCBS IL], et al, USDC D. Utah, No. 1:20-cv-184-RJS-CMR, 2023 WL 2634240 (Doc. 70, filed Mar. 24, 2023). Previously reported at MCLU Vol. 167.

RECENTLY FILED ACTIONS

M.C. v. Unitedhealthcare Insurance Company, et al., U.S.D.C. S.D. FL, Doc. No. 1:23-cv-21037-KMW, (filed Mar. 16, 2023). Member seeks ERISA benefits associated with "top" surgery. Plaintiff's request for prior authorization was denied as not covered because of the age of the beneficiary.

M.T., et al. v. Blue Cross Blue Shield of Illinois, et al., U.S.D.C. D. UT, Doc. No. 2:23-cv-186-HCN, (filed Mar. 16, 2023). Member seeks ERISA benefits from fully-insured plan associated with residential treatment at Evoke at Cascades and Equinox and the transportation to Evoke from another facility. Plaintiff alleges violations of MHPAEA. The claim for transportation was denied on the grounds non-emergency transportation is not considered medically necessary, and the Evoke claim was denied on the grounds of a wilderness program exclusion. The Equinox claim was denied on the grounds it did not meet the plan's criteria of a residential treatment center.

Kevin Keating v. Blue Cross Blue Shield of Illinois, U.S.D.C. W.D. WI, Doc. No. 3:23-cv-174-slc, (filed Mar. 17, 2023). Removed action in which member seeks benefits associated with orthopedic surgery. The claim was denied as not medically necessary and provider is balance billing member.

RECENTLY FILED ACTIONS

Racquel Lewis v. [ ], Highmark Health Insurance, U.S.D.C. D. DE, Doc. No. 1:23-cv-293-RGA, (filed Mar. 17, 2023). Pro se member alleges wrongful denial of prescription for "tretinoin cream." Plaintiff alleges the claim was denied due to her age.

Clarisol Mejia v. [ ], United Healthcare Services, et al., U.S.D.C. C.D. CA, Doc. No. 2:23-cv-2028-MEMF-MRW, (filed Mar. 17, 2023). Removed action in which member seeks $45,000 in ERISA benefits and alleges underpayment and wrongful denial of claims for which plaintiff is responsible. Plaintiff asserts the basis for denial was never provided.

Oscar Mejia v. [ ], United Healthcare Services, et al., U.S.D.C. C.D. CA, Doc. No. 2:23-cv-2032-SVW-E, (filed Mar. 17, 2023). Removed action in which member seeks $56,046 in ERISA benefits and alleges underpayment and wrongful denial of claims for which plaintiff is responsible. Plaintiff asserts the basis for denial was never provided.

Lindsey Salagaj v. [ ], United Healthcare Services, et al., U.S.D.C. C.D. CA, Doc. No. 2:23-cv-2035-JFW-JC, (filed Mar. 17, 2023). Removed action in which member seeks $87,592 in ERISA benefits and alleges underpayment and wrongful denial of claims for which plaintiff is responsible. Plaintiff asserts the basis for denial was never provided.

Mehdi Eskandarloo v. [ ],...