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Vorpahl v. Harvard Pilgrim Health Care Insurance Co.

United States District Court, D. Massachusetts

July 20, 2018

JACQUELINE VORPAHL, DANIELLE PASQUALE, and KATHERINE McGUIRE Plaintiffs,
v.
HARVARD PILGRIM HEALTH INSURANCE COMPANY, Defendant.

          MEMORANDUM AND ORDER

          DENISE J. CASPER, UNITED STATES DISTRICT JUDGE

         I. Introduction

         Jacqueline Vorpahl (“Vorpahl”), Danielle Pasquale (“Pasquale”) and Katherine McGuire (“McGuire”) (collectively, “Plaintiffs”) bring suit against Harvard Pilgrim Health Care Insurance Company (“Harvard Pilgrim”), their health insurance provider, related to Harvard Pilgrim's denial of coverage for certain services for their children. D. 16. Harvard Pilgrim now moves to dismiss the Plaintiffs' claims. D. 22. For the following reasons, the Court DENIES in part and ALLOWS in part Harvard Pilgrim's motion to dismiss.

         II. Standard of Review

         In evaluating a motion to dismiss, the Court takes all well-pleaded facts in the complaint as true and draws “all reasonable inferences” in favor of the plaintiffs. Manning v. Boston Medical Ctr. Corp., 725 F.3d 34, 43 (1st Cir. 2013).

         III. Factual Background

         The following facts are taken from the operative complaint, D. 16, and the Court accepts them as true for the purposes of resolving the motion to dismiss. Harvard Pilgrim is the provider of employer-sponsored health insurance for Plaintiffs and three of their children, who are covered under their parents' plans with Harvard Pilgrim. D. 16 ¶¶ 14, 15, 16. All three children have mental health issues and received treatment at Red Cliff, an “Outdoor Youth Treatment program” licensed by the state of Utah. D. 16 ¶¶ 20, 25, 28, 35. All three Plaintiffs sought coverage from Harvard Pilgrim for that treatment and were denied that coverage. D. 26 ¶¶ 21, 26, 29. Vorpahl and Pasquale appealed the denial of coverage, D. 16 ¶¶ 22, 26, and Harvard Pilgrim denied the appeal with a letter quoting or referencing language from the Harvard Pilgrim MA-PPO Benefit Handbook that “[h]ealth Resorts, recreational programs, camps, wilderness programs, outdoor skills programs, relaxation or lifestyle programs, including services provided in conjunction with, or as part of, such programs” were excluded from coverage. D. 16 ¶¶ 22, 26. Plaintiff McGuire did not appeal the denial of coverage because “she knew any appeal would be futile” based on this “blanket exclusion.” D. 16 ¶ 31. Due to Harvard Pilgrim's denial of coverage, all three Plaintiffs have paid thousands of dollars for the services provided by Red Cliff to their children. D. 16 ¶¶ 24, 27, 30.

         Red Cliff, as a state-licensed Outdoor Youth Treatment program in Utah, must adhere to the same “core rules” as Residential Treatment Centers in Utah, including the requirement to perform an intake evaluation, create an individualized treatment plan, create a discharge plan, and perform employee background checks. D. 16 ¶ 35. The staffing requirements established by Utah's licensing board for Outdoor Youth Treatment programs and Residential Treatment Centers are “substantially similar, ” with both programs requiring a licensed physician or consulting physician on staff, a 1:4 client to staff ratio and a multidisciplinary team including a “treatment professional” who must be a licensed psychologist, clinical social worker, professional counselor, marriage and family counselor, or school counselor. D. 16 ¶¶ 36, 37.

         Plaintiffs now bring suit, on behalf of a putative class, against Harvard Pilgrim under ERISA, contending that Harvard Pilgrim has denied them benefits and breached its fiduciary duty to adjudicate benefits determinations in accordance with applicable law, including the federal Parity Act and the Affordable Care Act. D. 16 ¶¶ 63-74.

         IV. Procedural History

         Plaintiffs filed the operative, amended complaint on August 25, 2017. D. 16. Harvard Pilgrim has now moved to dismiss. The Court heard argument regarding the motion and took the matter under advisement. D. 33. Since the hearing, the parties have filed notices of supplemental authorities (and responses to same) and the Court has considered those filings, D. 34, 36, 39, 40, 42-43) along with the parties' pre-hearing filings.

         V. Discussion

         Plaintiffs contend that the facts pled in the complaint state a claim for relief for three reasons: first, that the text of the exclusion referenced by Harvard Pilgrim does not cover treatment provided by Red Cliff, D. 30 at 9; second, to the extent that the exclusion does cover treatment provided by Red Cliff, the exclusion violates the Parity Act, D. 30 at 10; and third, to the extent that the exclusion does cover treatment provided by Red Cliff, the exclusion violates the Affordable Care Act, D. 30 at 19. While the complaint pleads two counts - one for benefits due and one for breach of fiduciary duty - both counts rely on the same three underlying claims.

         A. The Text ...


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