342 F. Supp. 3d 1311
S.D. Fla.2018Background
- Two plaintiffs (H.H. and V.G.) sued Aetna under ERISA and the Mental Health Parity and Addiction Equity Act after Aetna denied coverage for residential/wilderness therapy programs (Open Sky for H.H.; Aspiro for V.G.).
- Both plaintiffs exhausted Aetna's internal appeals; each paid tens of thousands for treatment and then had claims denied and appeals upheld.
- Each plaintiff originally sought class certification but later abandoned class claims and proceeded only individually.
- H.H.'s plan expressly covered "residential treatment" for mental disorders but defined detailed facility criteria (e.g., 24/7 licensed behavioral health provider, physician admission, comprehensive assessment).
- V.G.'s plan covered "residential treatment services" defined to require specialization in mental-health treatment and specific staffing/licensing; Aspiro was licensed in Utah as an "outdoor youth program," not as a residential treatment program.
- The court considered whether the complaints pleaded facts showing the programs met their plans' residential-treatment definitions and whether the Parity Act claims were adequately pleaded.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether plaintiffs sufficiently alleged that the facilities met their plans' residential-treatment definitions (ERISA coverage) | Plaintiffs allege the programs are licensed and provide psychiatric/medical oversight, so services are covered | Aetna says complaint lacks facts showing plan-defined criteria (24/7 licensed provider, physician admission, comprehensive intake) were met | Dismissed: plaintiffs failed to plead facts that facilities met plan definitions; ERISA coverage claims dismissed without prejudice |
| Whether Aspiro's Utah licensing qualifies it as a covered "residential treatment service" under V.G.'s plan | Plaintiffs contend Aspiro is regulated as residential treatment | Aetna points to public licensing records showing Aspiro is licensed only as an outdoor youth program (different, less stringent standards) | Dismissed: outdoor youth license insufficient to satisfy plan's residential-treatment licensing requirement |
| Whether plaintiffs pleaded a Parity Act violation (facial or as-applied) | Plaintiffs claim Aetna effectively excludes coverage for residential mental-health programs and applies more stringent processes to them than to analogous medical/surgical benefits | Aetna argues the plans do cover residential treatment (no blanket exclusion) and plaintiffs failed to identify comparable medical/surgical analogues or factual support for differing NQTL processes | Dismissed: Parity Act claims inadequately pleaded—plaintiffs provided only conclusory allegations and did not identify specific comparable limitations or processes |
| Whether Aetna was barred from raising new coverage/definitional arguments in district court because it did not raise them in administrative appeals | Plaintiffs invoke cases barring new post‑hoc rationales | Aetna notes Eleventh Circuit authority permits consideration of post‑hoc explanations and that the denial letter already argued deficiency of facility level-of-service | Court found no controlling Eleventh Circuit bar; argument not foreclosed and denial rationale matched litigation arguments |
Key Cases Cited
- Morgan v. Christensen, [citation="582 F. App'x 806"] (11th Cir. 2014) (pleading standard and view of facts on 12(b)(6))
- Bell Atl. Corp. v. Twombly, 550 U.S. 544 (pleading requires factual matter to state a plausible claim)
- Am. Psychiatric Ass'n v. Anthem Health Plans, Inc., 821 F.3d 352 (2d Cir.) (Parity Act’s purpose and requirements)
- A.Z. by & through E.Z. v. Regence Blueshield, 333 F. Supp. 3d 1069 (W.D. Wash.) (requires identification of the relevant treatment limitation for Parity claims)
- Harlick v. Blue Shield of Cal., 686 F.3d 699 (9th Cir. 2012) (on limits of post‑hoc rationales in ERISA appeals)
- Spradley v. Owens‑Illinois Hourly Emp. Welfare Benefit Plan, 686 F.3d 1135 (10th Cir. 2012) (similar administrative‑record arguments)
- Tippitt v. Reliance Standard Life Ins. Co., [citation="276 F. App'x 912"] (11th Cir. 2008) (district court may consider post‑hoc explanations)
- Daniels‑Hall v. Nat'l Educ. Ass'n, 629 F.3d 992 (9th Cir. 2010) (permitting judicial notice of publicly available government documents)
- Henderson v. Sun Pharm. Indus., Ltd., 809 F. Supp. 2d 1373 (N.D. Ga. 2011) (judicial notice of government‑produced records)