Danny P. v. Catholic Health Initiatives, ___ F.3d ___, 2018 WL 2709733 (9th Cir. June 6, 2018)
A self-funded group health benefit plan covering Catholic Health Initiatives’ employees and their dependents (the Plan) denied room and board coverage for plaintiff Nicole B., who was admitted to a residential treatment program for mental health issues. After exhausting the Plan’s administrative remedies, Plaintiffs brought an action under ERISA for wrongful denial of benefits. The district court granted summary judgment for the Plan, ruling that the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (the Mental Health Parity Act) did not prohibit the Plan from providing coverage for mental health stays at licensed treatment facilities that was more restrictive than coverage for stays at skilled nursing facilities. Plaintiffs appealed.
The Ninth Circuit reversed, holding that the Mental Health Parity Act precluded the Plan from differentiating room-and-board reimbursements for skilled nursing facility stays from mental health treatment facility stays. The Ninth Circuit found the general language of the statute to be “quite clear” in directing that benefits and treatment limitations for mental health problems shall be “no more restrictive” than those for medical and surgical problems. The Ninth Circuit found no contradiction between its reading of the Act and the Interim Final Rules, which indicated that mental and medical/surgical benefits must be congruent, and that limiting the former while not placing a similar limitation on the latter would be improper.
Prepared by H. Thomas Watson and Peder K. Batalden, Horvitz & Levy, LLP
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