291 F.R.D. 601
W.D. Wash.2013Background
- Plaintiffs allege Regence violated Washington’s Mental Health Parity Act by denying coverage for neurodevelopmental therapy (speech, occupational, and behavioral) for DSM-IV-TR conditions.
- The Parity Act phases permitted certain coverage limitations in early phases, but not impermissible exclusions; phase three required parity for treatment limitations and other financial requirements.
- J.T. is a minor who was denied neurodevelopmental therapy coverage due to an age-based cap (six years old), causing a direct claim under ERISA-governed plans.
- S.A. is a DRW plan beneficiary with Down syndrome; her plan limits neurodevelopmental therapy to age six and under with a DSM-IV condition and includes a separate rehabilitation benefit with a $1500 annual cap.
- S.A. sought class certification and declaratory/injunctive relief to require Regence to cover therapies under the mental health services benefit; Regence disputed standing and applicability of the Parity Act.
- The court ultimately denied defendants’ Rule 12(b)(1) motion to dismiss, denied S.A.’s class certification, and denied S.A.’s partial summary judgment.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the court has subject matter jurisdiction over J.T.’s claims. | J.T. has standing as a plan beneficiary harmed by an age-based exclusion. | J.T.’s plan not subject to Phase 3 parity; exclusion was permissible before Phase 3. | Jurisdiction exists; J.T. has standing to pursue his ERISA claims. |
| Whether S.A. has Article III standing to pursue ERISA claims. | S.A. has DSM-IV-TR diagnoses, expected therapy, and costs exceeding the $1500 cap; injury is concrete. | S.A. must show concrete injury and redressable harm; some claims lack injury. | S.A. has standing to pursue equitable relief and §502(a)(1)(B)/(a)(3) claims to the extent framed. |
| Whether S.A. can pursue class certification under Rule 23. | Class should include tens of thousands of members with common parity issues. | S.A.’s claims are not typical or adequately representative; evolving, non-common questions. | Court DENIES S.A.’s motion to certify the class. |
| Whether S.A. is entitled to partial summary judgment on declaratory/injunctive relief regarding coverage. | Regence must cover neurodevelopmental therapies under the mental health benefit per Parity Act. | Parity analysis allows limits; neurodevelopmental and rehabilitation benefits are distinct. | Court DENIES S.A.’s partial summary judgment. |
Key Cases Cited
- Mass. Mut. Life Ins. Co. v. Russell, 473 U.S. 134 (U.S. 1985) (remedial relief must benefit the plan; no monetary relief to individual plaintiffs)
- Ziegler v. Conn. Gen. Life Ins. Co., 916 F.2d 548 (9th Cir. 1990) (ERISA fiduciary duty suits may seek equitable relief for plan benefit)
- Shaver v. Operating Engineers Local 428 Pension Trust Fund, 332 F.3d 1198 (9th Cir. 2003) (equitable relief available even without monetary loss)
- Wal-Mart Stores, Inc. v. Dukes, 131 S. Ct. 2541 (U.S. 2011) (rigorous class-certification analysis requires common questions and adequate representation)
- Comcast Corp. v. Behrend, 133 S. Ct. 1426 (U.S. 2013) (district court must assess class-certification questions with merits overlap)
- Lujan v. Defenders of Wildlife, 504 U.S. 555 (S. Ct. 1992) (standing requires actual or imminent injury, causation, and redressability)
- Aetna Health Inc. v. Davila, 542 U.S. 200 (S. Ct. 2004) (ERISA fiduciary actions arise from plan administration)