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Unconventional Treatment Options and Plan Coverage: W.D. Wash.

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  • Unconventional Treatment Options and Plan Coverage: W.D. Wash.

    Here's a class action against Microsoft stemming from the self-funded plan's denial of coverage for non-conventional treatment options. The Plaintiff in this case is a beneficiary of he Plan based on his mother's employment with Microsoft, and he suffers from mental illness and substance abuse issues. After more conventional methods failed to adequately treat the Plaintiff, he enrolled in a "wilderness therapy" program and submitted bi-monthly claims to the Plan Administrator. His claim was denied, internal appeals exhausted, and this suit followed.

    The Plaintiff argues that denial of costs for the program represents a breach in fiduciary duties. The court reasons:

    The Plan covers medically necessary treatment for “mental health such as, but not limited to the diagnosis and treatment of psychiatric disorders . . . [and] chemical dependency such as substance abuse and alcoholism,” so long as the treatment is “furnished by an eligible provider.”4 (Dkt. No. 27 at 62.) Under the Plan, an “eligible provider” of mental health or chemical dependency treatment includes any “provider or facility who is licensed or certified by the state in which the care is rendered and who is providing care within the scope of their license or certification.” (Dkt. No. 27 at 63.) Plaintiff asserts that Wingate meets the Plan’s generic definition of an “eligible provider” and therefore is not subject to the Plan’s wilderness program exclusion. (Dkt. No. 31 at 14–15.) Defendants argue that Plaintiff’s suggested interpretation contradicts the plain terms of the Plan and would vitiate the wilderness program exclusion. (Dkt. No. 26 at 13.)
    It is undisputed that Wingate is a wilderness therapy program licensed by the State of Utah to provide “outdoor youth treatment.” (Dkt. No. 25-1 at 111.) Plaintiff alleges in his amended complaint that Wingate is statutorily authorized to provide “behavioral, substance abuse, or mental health services to minors.” (Dkt. No. 25 at 5) (citing UT § 62A-2-101(40)). Plaintiff further alleges that he received a psychiatric assessment when he arrived at Wingate as well as substance abuse and mental health services while attending the program. (Id. at 5–6.) Based on these allegations, Wingate meets the Plan’s generic definition of an “eligible provider” because it is a state-licensed provider that rendered care to Plaintiff within the scope of its license while Plaintiff attended the program.
    Next, the court shifts its focus to whether or not the Plan's "wilderness program exclusion" precludes coverage in this instance.

    The Plan expressly excludes coverage for “[e]ducational or recreational therapy or programs; this includes, but is not limited to boarding schools and wilderness programs. . . .” (Dkt. No. 27 at 64.) This specific exclusion of wilderness programs appears to limit the Plan’s broader coverage of services rendered by eligible providers. See Brinderson-Newberg Joint Venture v. Pac. Erectors, Inc., 971 F.2d 272, 279 (9th Cir. 1992) (“[w]here there is an inconsistency between general provisions and specific provisions, the specific provisions ordinarily qualify the meaning of the general provisions.”) (citing Restatement of Contracts § 236(c) (1932)).
    However, the second sentence of the exclusion provides an exception that states: “Benefits may be provided for medically necessary treatment received in these locations if treatment is provided by an eligible provider.” (Dkt. No. 27 at 64.) Plaintiff asserts that the exception to the exclusion “properly recognizes that some wilderness programs are not merely ‘educational or recreational,’ but are licensed mental health and substance abuse treatment programs that happen to be located in a setting other than a building.” (Dkt. No. 31 at 15.) Plaintiff argues that the second sentence of the exclusion applies to Wingate because it qualifies under the Plan’s definition of an eligible provider. (Id. at 14–15.) Applied to the facts of this case, Plaintiff argues that this clause should be interpreted to read “benefits may be provided for medically necessary treatment received in [the wilderness] if treatment is provided by [Wingate].” (Dkt. No. 31 at 15.)
    The court concludes that the Plaintiff plausibly establishes that Wingate was an eligible provider, and denied the Defendant's motion to dismiss with respect to the first and second claims. However, the court dismisses the Plaintiff's claims with respect to the Parity Act, the Affordable Care Act, and claim two with leave to amend. The opinion is attached below.
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