Wilson v. Anthem Health Plans of Ky., Inc.

• Decision Date: 03 January 2017
• Docket Number: CIVIL ACTION NO. 3:14-CV-743-TBR
• Parties: MARGARET WILSON, individually and on behalf of a Class of persons similarly situated, PLAINTIFF v. ANTHEM HEALTH PLANS OF KENTUCKY, INC., DEFENDANT
• Court: U.S. District Court — Western District of Kentucky

MARGARET WILSON, individually and on behalf of a Class of persons similarly situated, PLAINTIFF v. ANTHEM HEALTH PLANS OF KENTUCKY, INC., DEFENDANT

CIVIL ACTION NO. 3:14-CV-743-TBR

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF KENTUCKY AT LOUISVILLE

January 3, 2017

MEMORANDUM OPINION AND ORDER

This matter is before the Court on two pending motions. First, Plaintiff Margaret Wilson filed a Motion for Class Certification pursuant to Federal Rule of Civil Procedure 23. [DN 37.] Defendant Anthem Health Plans of Kentucky, Inc. ("Anthem") responded. [DN 41.] Plaintiff replied. [DN 44.] Second, Plaintiff filed a Motion to Strike Undisclosed Evidence and Testimony. [DN 43.] Defendant responded. [DN 45.] No replies were filed. Fully briefed, these matters are now ripe for adjudication. For the reasons stated herein, the Court will GRANT Plaintiff's Motion for Class Certification and DENY Plaintiff's Motion to Strike as moot.

BACKGROUND

Plaintiff Wilson is the mother of M.W., a minor child with Autism Spectrum Disorder ("ASD"). [DN 1 at 1-2.] Both Wilson and M.W. are beneficiaries under a health benefit plan provided by Defendant Anthem (the "Anthem Plan") under ERISA. [Id.] To obtain treatment for M.W.'s ASD, Wilson and M.W. have travelled to several different states and internationally. [Id. at 10.] In 2009, when M.W. was twelve years old, Wilson and M.W. moved back to Kentucky from Georgia, where they had been living to obtain treatment for M.W.'s ASD, and enrolled M.W. in a treatment program at a new facility in Prestonburg, Kentucky. [Id.] The facility, called the Highlands Center for Autism, offers a type of treatment known as Applied Behavior Analysis ("ABA"), a well-recognized treatment for ASD. [Id. at 3; 10-11.] M.W. received treatment at the Highlands Center until Spring 2014, during which time he "received appropriate care and experienced significant progress in communication, cognition, and activities of daily living." [Id. at 11.] Wilson submitted claims to Anthem seeking coverage for M.W.'s treatment, and was reimbursed some amounts, but "the vast majority of the cost of that treatment has gone unreimbursed." [Id.] Wilson further claims that Anthem limited coverage of claims for treatment M.W. received from other sources after leaving the Highlands Center and that, in total, Wilson has been denied "tens of thousands of dollars" in reimbursements. [Id.]

The Anthem Plan does provide coverage for ASD and ABA treatment, but places limitations on that coverage. The Anthem Plan states, in relevant part:

The diagnosis and treatment of Autism Spectrum Disorders for Members ages one (1) through twenty-one (21) is covered. Autism Spectrum Disorders means a physical, mental, or cognitive illness or disorder which includes any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders ("DSM") published by the American Psychiatric Association, including Autistic Disorder, Asperger's Disorder, and Pervasive Developmental Disorder Not Otherwise Specified.

Treatment for autism spectrum disorders includes the following care for an individual diagnosed with any of the autism spectrum disorders:

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• Applied behavior analysis prescribed or ordered by a licensed health or allied health professional. Applied behavior analysis means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior

[DN 1-1 at 26-27.] Other ASD treatments identified in the Anthem Plan in addition to ABA include medical care, habilitative or rehabilitative care, pharmacy care, psychiatric care, psychological care, and therapeutic care. [Id. at 27.]

The Anthem Plan limits coverage for ASD treatment to 1,000 hours per year for members ages one through their seventh birthday and 20 hours per month for members ages seven through twenty-one. [Id. at 15.] It is these hour limitations, in addition to similar dollar limitations Anthem places on ASD treatment coverage, that Wilson contends are unlawful under the Employee Retirement Income Security Act of 1974 ("ERISA") and the Mental Health Parity and Addiction Equity Act ("MHPAEA"). [DN 1 at 1; DN 38 at 1.]

"Congress enacted the MHPAEA [in 2008] to end discrimination in the provision of insurance coverage for mental health and substance use disorders as compared to coverage for medical and surgical conditions in employer-sponsored group health plans." Am. Psychiatric Ass'n v. Anthem Health Plans, Inc., 821 F.3d 352, 356 (2d Cir. 2016) (citing Coalition for Parity, Inc. v. Sebelius, 709 F.Supp.2d 10, 13 (D.D.C. 2010)). The 2008 statute "expanded the scope of prior legislation, the Mental Health Parity Act of 1996." Id. The MHPAEA provides, in part:

(2) Annual limits

In the case of a group health plan or a health insurance issuer offering group or individual health insurance coverage that provides both medical and surgical benefits and mental health or substance use disorder benefits—

(A) No annual limit

If the plan or coverage does not include an annual limit on substantially all medical and surgical benefits, the plan or coverage may not impose any annual limit on mental health or substance use disorder benefits.

(B) Annual limit

If the plan or coverage includes an annual limit on substantially all medical and surgical benefits (in this paragraph referred to as the "applicable annual limit"), the plan or coverage shall either—

(i) apply the applicable annual limit both to medical and surgical benefits to which it otherwise would apply and to mental health and substance use disorder benefits and not distinguish in the application of such limit between such medical and surgical benefits and mental health and substance use disorder benefits; or

(ii) not include any annual limit on mental health or substance use disorder benefits that is less than the applicable annual limit.

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(3) Financial requirements and treatment limitations

(A) In general

In the case of a group health plan or a health insurance issuer offering group or individual health insurance coverage that provides both medical and surgical benefits and mental health or substance use disorder benefits, such plan or coverage shall ensure that—

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(ii) the treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage) and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits.

42 U.S.C. § 300gg-26(2); (3)(A)(ii). Examples of "[t]reatment limitations include: 'limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment.'" Smith v. U.S. Office of Pers. Mgmt., 80 F. Supp. 3d 575, 578-79 (E.D. Pa. 2014) (quoting 42 U.S.C. § 300gg-26(a)(3)(B)(iii)). "Congress enacted the [MHPAEA] as an amendment to ERISA, making it enforceable through a cause of action under 29 U.S.C. § 1132(a)(3) as a violation of a 'provision of this subchapter.'" Joseph F. v. Sinclair Servs. Co.,158 F. Supp. 3d 1239, 1259 n.118 (D. Utah 2016) (citing A.F. ex rel. Legaard v. Providence Health Plan, 35 F.Supp. 3d 1298, 1304 (D. Or. 2014); 29 U.S.C. § 1132(a)(3)(A)-(B)).

Wilson alleges that the Anthem Plan does not impose limitations on medical and surgical benefits as it does for ASD, and therefore that the limitations the Anthem Plan places on ASD treatment violate the MHPAEA. [DN 1 at 5-7.] Accordingly, in the instant motion, Wilson seeks certification of the following class of individuals:

All persons who are or have been insureds, participants in, or beneficiaries of a health insurance policy issued or administered by Anthem Health Plans of Kentucky, Inc., which contains dollar limits on the provision of treatment for Autism Spectrum Disorders and who have made a claim for, and have been denied coverage or reimbursement for Applied Behavior Analysis treatment for Autism Spectrum Disorders on the grounds that the policy's dollar limits had been exceeded.

[DN 38 at 2.]

Anthem vigorously opposes class certification, however, making, in essence, two main arguments in response: 1) "under state and federal law, ASD may or may not be a mental health condition, depending on the individual," and 2) "whether ABA therapy is a 'mental health benefit' is also not a question that could be answered on a class-wide basis" bur rather requires individualized determinations based upon each individual's treatment plan. [DN 41 at 29; 31.] At the core of each of these arguments is the assertion that this case presents overwhelmingly individual issues so as to make a class action an improper method for resolving this dispute. The Court will address these arguments in detail below.

STANDARD

"A district court has broad discretion to decide whether to certify a class." In re Whirlpool Corp. Front-Loading Washer Prod. Liab. Litig., 722 F.3d 838, 850 (6th Cir. 2013) (citing In re Am. Med. Sys., Inc., 75 F.3d 1069, 1079 (6th Cir. 1996)). "Class certification isappropriate if the court finds, after conducting a 'rigorous analysis,' that the requirements of Rule 23 have been met." Id. at 851 (citing Wal-Mart Stores, Inc. v. Dukes, 564 U.S. 338, 351 (2011); Young v. Nationwide Mut. Ins. Co., 693 F.3d 532, 537 (6th Cir. 2012); Daffin v. Ford Motor Co., 458 F.3d 549, 552 (6th Cir. 2006)). In conducting such an analysis, courts must bear in mind that class certification is an "exception to the usual rule that litigation is conducted by and on behalf of the individual named parties only." Davis v. Cintas Corp., 717 F.3d 476, 483 (6th Cir. 2013) (quoting Califano v. Yamasaki, ...