Insurer On the Hook in Breastfeeding Case

WASHINGTON (CN) – A federal judge ruled that an insurance provider must face claims that it broke the law when it refused to fully pay for three women’s access to breastfeeding services as required by the Affordable Care Act.

U.S. District Judge Amit Mehta ruled in favor of the women on Monday in a five-page decision.

Lindsay Ferrer filed the class-action complaint against CareFirst Inc. in October 2016. Ferrer and two other women, Amy Haddad and Sarah Sorscher, claimed the health insurance giant refused to honor stipulations laid out in the Patient Protection and Affordable Care Act, or ACA, also called Obamacare.

According to Mehta’s ruling, the ACA mandates coverage for lactation services – including breastfeeding support, supplies and counseling services – as a “no cost preventative service and thus requires issuers… either to offer in-network providers for lactation services or, in the absence of in-network providers, cover the full cost of out-of-network services.”

Ferrer, Haddad and Sorscher claimed that CareFirst offered them no options for in-network providers, forcing them to go out of the network and endure the full cost while paying a portion out of pocket.

CareFirst argued that while ACA mandates coverage for breastfeeding services, it does not require an insurance company to cover the full costs when an enrolled member uses an out-of-network provider.

“Instead, CareFirst insists, under the ACA an insurer is permitted to ‘balance bill,’ that is, charge the insured the difference between the allowed benefit under a plan and the total amount billed by an out of network provider,” Judge Mehta wrote.

Mehta also noted CareFirst never filed a motion to dismiss for failure to state a claim. Instead, the insurance company argued the complaint should be dismissed because the women lacked standing to sue as they didn’t suffer any injuries.

An affidavit from CareFirst employee Wanda Lessner explained that the company only billed the plaintiffs for the additional amount charged by the out-of-network provider, or the “balanced-bill amount.”

The insurer argued the affidavit was evidence that each plaintiff received the maximum amount of benefits allowed under their health care plans.

But Judge Mehta said he didn’t consider the affidavit in his ruling for procedural reasons.

“CareFirst’s reliance the Lessner affidavit is improper at this stage of litigation. Haase [v. Sessions] forbids a defendant from assuming the correctness of its legal theory and offering its own evidence to negate a plaintiff’s alleged injury,” he wrote. “Instead, under Rule 12(b)(1), the factual allegations contained in plaintiffs’ complaint—plaintiffs offer no outside evidence—are the focus of the standing inquiry. CareFirst’s motion is thus fundamentally flawed because it does precisely what Haase says it cannot.”

Rejecting the insurer’s motion to dismiss, Mehta found that the women do have standing to sue because they sufficiently claimed an injury stemming from CareFirst’s alleged failure to adhere to ACA standards.

“Economic harm, even a dollar’s worth, is sufficient to establish injury,” the judge wrote. “Here, each plaintiff alleges that CareFirst’s denial of full coverage resulted in each plaintiff having to pay hundreds of dollars out of pocket for lactation services, thereby easily meeting the injury in-fact requirement.”

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