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An AT&T Inc. health plan must pay for an employee’s daughter’s mental health treatment at a residential center that combines psychotherapy with riding horses ( Lynn R. v. ValueOptions , 2017 BL 293893, D. Utah, No. 2:15-cv-00362-RJS-PMW, 8/22/17 ).
The health plan was wrong to deny more than $117,000 in medical claims for treatment the girl received at Utah-based Equine Journeys, a federal judge ruled Aug. 22. The plan said it denied coverage because the facility wasn’t nationally accredited, but the judge rejected this rationale. “Nowhere does the Plan state a provider must be nationally accredited for the treatment to be medically necessary,” the judge said.
The case was brought by Brian S. King, a Utah attorney who specializes in Employee Retirement Income Security Act cases. In the past year, King has filed more than two dozen lawsuits against health insurers, including Cigna, United Healthcare, and Aetna, challenging their decisions to deny coverage for medical expenses incurred by minors with mental health conditions at residential treatment facilities, according to Bloomberg Law data analysis. Some of King’s cases involve nontraditional therapy programs, including ones that take place in outdoor and wilderness settings.
In this case, the judge said the health plan was wrong to use national accreditation as a proxy for determining whether a particular treatment is “in accordance with generally accepted United States medical standards,” which is the coverage standard set forth in the plan. The plan is also barred from using the alleged failure to seek preauthorization as a reason to deny benefits, the judge said, because the plan failed to cite this as a justification when it initially denied the claim.
After determining that it would be futile to send the claim back to the plan for reconsideration, the judge ordered the plan to cover the girl’s treatment. He also said he would consider awarding her attorneys’ fees and prejudgment interest.
Judge Robert J. Shelby of the U.S. District Court for the District of Utah wrote the decision.
Campbell Litigation PC represented AT&T. Christian & Barton LLP and Parsons Behle & Latimer represented the health plan’s claims administrator.
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