796 F.Supp.3d 744
D. Utah2025Background
- Plaintiffs L.R. and M.R. sued Blue Cross Blue Shield of Illinois and the Mayer Brown LLP Benefit Plan after coverage was denied for M.R.'s inpatient mental health treatment at Mountain Valley Treatment Center (NH) and Waypoint Academy (UT).
- Both facilities did not provide 24-hour onsite nursing, which is explicitly required by the terms of the Plan for a "Residential Treatment Center."
- Blue Cross denied coverage and subsequent appeals, stating the facilities did not meet the definition of a Residential Treatment Center under the Plan.
- Plaintiffs alleged ERISA violations for improper denial of benefits and a Parity Act (Mental Health Parity and Addiction Equity Act) violation due to the 24-hour nursing requirement.
- Both sides moved for summary judgment and to exclude expert testimony; the court granted summary judgment for defendants and denied all Daubert motions as moot.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Improper Denial of Benefits under ERISA | The Plan covers medically necessary mental health treatment at any licensed provider, even without 24-hour nursing | Coverage is expressly limited to facilities with 24-hour onsite nursing for residential treatment centers; no coverage here | For Defendant - No coverage since the facilities did not meet Plan's definition |
| Parity Act Violation - 24-hr nursing exceeds medical equivalents | Plan imposes stricter requirement for mental health (residential centers) than for analogous medical/surgical facilities | Plan imposes same requirement on medical analogues (skilled nursing, rehab) via state licensing; no facial or as-applied disparity | For Defendant - No Parity Act violation, requirements reasonably consistent |
| Parity Act - Exceeds generally accepted standard of care | Requiring 24-hr nursing for mental health is not consistent with generally accepted standards | 24-hr nursing is within accepted standards per AACAP Principles; not arbitrary | For Defendant - Requirement is consistent with standards of care |
| Disparate Impact Parity Act Claim | 24-hr nursing requirement limits availability of mental health care more than medical care | Plan consistently applies the same limitation to both; disparate impact alone is not actionable | For Defendant - Disparate impact alone does not violate Parity Act |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (de novo review of benefits under ERISA unless discretionary authority is granted)
- LaAsmar v. Phelps Dodge Corp. Life, Accidental Death & Dismemberment & Dependent Life Ins. Plan, 605 F.3d 789 (summary judgment posture for ERISA claims)
- Kellogg v. Metropolitan Life Ins. Co., 549 F.3d 818 (review limited to rationale for benefits denial)
- Church of Lukumi Babalu Aye, Inc. v. City of Hialeah, 508 U.S. 520 (examining treatment of facially neutral law in context)