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D.T. v. Neca/Ibew Family Medical Care Plan

United States District Court, W.D. Washington, Seattle

November 28, 2017

D.T. by and through his parents and guardians, K.T. and W.T., individually, on behalf of similarly situated individuals, and on behalf of the NECA/IBEW Family Medical Care Plan Plaintiff,
v.
NECA/IBEW FAMILY MEDICAL CARE PLAN, THE BOARD OF TRUSTEES OF THE NECA/IBEW FAMLY MEDICAL CARE PLAN, SALVATORE J. CHILIA, ROBERT P. KLEIN, DARRELL L. MCCUBBINS, GEARY HIGGINS, LAWRENCE J. MOTER, JR., KEVIN TIGHE, JERRY SIMS, AND ANY OTHER INDIVIDUAL MEMBER OF THE BOARD OF TRUSTEES OF NECA/IBEW FAMILY MEDICAL CARE PLAN, Defendants.

          ORDER

          Honorable Richard A. Jones United States District Judge

         This matter comes before the Court on Defendants NECA/IBEW Family Medical Care Plan (the “Plan” or “FMCP”), the Board of Trustees of the FMCP, Salvatore J. Chilia, Robert P. Klein, Darrell L McCubbins, Geary Higgins, Lawrence J. Moter, Jr., Kevin Tighe, and Jerry Sims' (collectively “Defendants”) Motion to Dismiss. Dkt. # 11. Plaintiff opposes the motion. Dkt. # 16. For the reasons that follow, the Court DENIES the motion.

         I. BACKGROUND

         Plaintiff D.T., a three-year-old dependent on his parent's NECA/IBEW Family Medical Care Plan (“Plan”), was diagnosed with a developmental mental health condition. Dkt. # 1 (Complaint) at ¶¶ 1, 22. D.T. sought coverage for either neurodevelopmental therapies (NDT) or Applied Behavior Analysis (ABA) therapy but was denied under his Policy's Development Delay Exclusion. According to Plaintiff, this exclusion is a “uniform policy excluding all coverage for NDT and ABA therapies to treat developmental mental health conditions like ASD, even when medically necessary.” Id. at ¶ 9. Plaintiff further claims that the Policy covers other benefits associated with developmental mental health conditions, and therefore the uniform exclusion of coverage for NDT and ABA therapy is a violation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (“Federal Parity Act”).

         Defendants argue that the Policy legitimately excludes coverage for any developmental mental health conditions, and therefore there is no Federal Parity Act violation for its refusal to cover NDT or ABA therapy benefits. Defendants are now before the Court seeking dismissal of Plaintiff's Complaint under Rule 12(b)(6).

         II. LEGAL STANDARD

         Fed. R. Civ. P. 12(b)(6) permits a court to dismiss a complaint for failure to state a claim. The rule requires the court to assume the truth of the complaint's factual allegations and credit all reasonable inferences arising from those allegations. Sanders v. Brown, 504 F.3d 903, 910 (9th Cir. 2007). A court “need not accept as true conclusory allegations that are contradicted by documents referred to in the complaint.” Manzarek v. St. Paul Fire & Marine Ins. Co., 519 F.3d 1025, 1031 (9th Cir. 2008). The plaintiff must point to factual allegations that “state a claim to relief that is plausible on its face.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 568 (2007). If the plaintiff succeeds, the complaint avoids dismissal if there is “any set of facts consistent with the allegations in the complaint” that would entitle the plaintiff to relief. Id. at 563; Ashcroft v. Iqbal, 556 U.S. 662, 679 (2009).

         A court typically cannot consider evidence beyond the four corners of the complaint, although it may rely on a document to which the complaint refers if the document is central to the party's claims and its authenticity is not in question. Marder v. Lopez, 450 F.3d 445, 448 (9th Cir. 2006).

         III. DISCUSSION

         A. Federal Parity Act

         The parties agree that the Federal Parity Act allows group plans to invoke blanket exclusions. See Dkt. ## 11 at 8 (“The Federal Parity Act does not mandate coverage of mental health benefits.”), 16 at 18 (“Under the Parity Act, a group plan need not offer any mental health benefits.”). However, once a group plan decides to provide coverage for mental health benefits, then it may not apply “any financial requirement or treatment limitation to mental health or substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all medical/surgical benefits in the same classification.” 29 C.F.R. § 2590.712(c)(2)(i). “A permanent exclusion of all benefits for a particular condition or disorder, however, is not a treatment limitation[.]” 29 C.F.R. § 2590.712(a).

         The Policy covers certain “mental health or nervous disorder” benefits. The definition of “mental or nervous disorder” is broadly defined:

A neurosis, psychoneurosis, psychopathy, psychosis or mental or emotional disease or disorder of any kind, regardless of whether such condition, disease or disorder has causes or origins which are organic, physiological, traumatic or functional.

Dkt. # 11-3 at 24 (defining “mental or nervous disorder”). It is unclear whether autism spectrum disorder (ASD) falls within the definition. The Complaint claims that it does. See also Dkt. # 16 at 12 (Plaintiffs reiterate that the definition ...


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