INDIANAPOLIS (CN) - Indiana University's health insurer will cover treatments for drug abuse or eating disorders, but not for mental illness, and the unfair policy forced a student to drop out, he claims in Federal Court.
J. Doe's parent is an employee of Indiana University.
The university's "third-party health plan administrator, Anthem Blue Cross Blue Shield has denied benefits for over $100,000 of plaintiff's expenses incurred over the 29-month period preceding the filing of this complaint in the course of plaintiff's receipt of services at various types of inpatient facilities in five different states that were qualified to treat plaintiff's illnesses," the complaint states.
Blue Cross is not a defendant. The only defendants are the university and its Associate Vice President of Human Resources Daniel Rives, in his official capacity.
Doe claims that under President George W. Bush's 2008 mental health insurance parity law (MHPAEA), the university is required to design its plan "such that (a) the treatment limitations applicable to mental health benefits under such plans are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the IU plans, and (b) there are no separate treatment limitations that are applicable only with respect to mental health benefits."
Regardless of the legal requirements, Doe says, "claims with an aggregate dollar amount of [at] least $50,000 were denied by defendant IU's agent, Anthem, not based on any medical judgment (or even inquiry) as to the necessity or appropriateness of the treatment that was provided (or to be provided) to plaintiff in exchange for the services for which benefits were denied. Rather, as to such denials, defendant IU's agent, Anthem, categorically refused to pay any claims that might be submitted by certain facilities ... based on an exclusion in the IU plan ... that purports to bar coverage for benefits for '[c]are provided or billed by residential treatment centers or facilities.'" (Parentheses in complaint.)
The "residential facilities" include programs for patients suffering from substance abuse or eating disorders, but Doe says IU "has categorically excluded mental health benefits for services provided by or billed by many such inpatient facilities, and threatens to continue to do so."
In denying benefits for mental health illnesses, IU "has construed the plans as covering services or care provided by all or substantially all types of specialty non-hospital providers of inpatient services to patients whose needs were not principally related to mental health or behavioral health illnesses or disorders," according to the complaint.
"Specifically, defendant IU has at all relevant times paid benefits under specific insuring provisions of the plans, without regard to any Residential Exclusion of the plans, for inpatient treatment at those types of non-hospital facilities that are defined by the plans as skilled nursing facilities, hospices, and inpatient physical medicine and rehabilitation facilities when such inpatient treatment is provided to patients who needed specialized care for illnesses or conditions (other than those related principally to mental health or behavioral health illnesses or disorders)." (Parentheses in complaint.)
Doe seeks declaratory judgment that the IU insurance plans violate federal and state parity Laws, and compensatory and punitive damages.
Doe is represented by Mark Barnes.
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