Denial of ‘Wilderness’ Mental Health Claim did not Violate MHPAEA
A federal judge has ruled that a health plan’s denial of a claim for inpatient mental health “wilderness” treatment did not violate the Mental Health Parity and Addiction Equity Act (MHPAEA) because the health plan’s exclusion for wilderness treatment programs (WTP) applied equally to mental health care and medical/surgical services.
The health plan participant’s teenage son struggled for several months with drug addiction, depression, and other mental disorders and, as a result, he was placed in an adolescent WTP, where mental health treatment is combined with outdoor activities designed to instill self-confidence and boost self-esteem (e.g., rock climbing, hiking, backpacking, biking).
When the plan participant submitted the WTP claim to the health plan, the claim was denied because, according to the terms of the plan, WTPs are specifically excluded from coverage. After all of the subsequent appeals were denied, the plan participant sued, alleging that the exclusion of WTPs from mental health benefits under the plan places a limit on mental health benefits, but because no such limit is imposed on comparable medical/surgical benefits, the plan participant asserted, the health plan violated the MHPAEA.
In order to prevail in a lawsuit alleging a violation of the MHPAEA, the court noted, a plaintiff must demonstrate that: (1) the health plan is subject to the MHPAEA; (2) the plan provides benefits for both mental health/substance abuse and medical/surgical treatments; (3) the plan places differing limitations on benefits for mental health care as compared to those that apply to benefits for medical/surgical care; and (4) the plan’s limitations on mental health care are more restrictive than those that apply to medical/surgical care.
Here, the court examined the health plan’s summary plan description and found that the health plan’s list of “medical plan exclusions” included “[w]ilderness treatment programs (whether or not the program is part of a licensed residential treatment facility, or otherwise licensed institution).”
Thus, because the exclusion language for WTPs appears under the health plan’s general heading for medical plan exclusions, the court concluded that the exclusion applies to all WTPs and does not apply exclusively to mental health care WTPs. Although the court acknowledged that the vast majority of WTPs are for mental health/substance abuse treatment, it noted that WTPs also exist for medical/surgical care, such as for weight loss treatment and for long-term treatment of childhood cancer survivors. Therefore, because the health plan excluded coverage for all WTPs on an equal basis, the plan did not violate the MHPAEA.
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