Court Reverses Mental Health Benefits Denial

Case Background

Dan C. sued Anthem Blue Cross Life and Health Insurance Company and others over denied mental health benefits under an ERISA-governed plan. The dispute centered on claims for R.C.’s residential treatment at Intermountain. The plaintiff alleged that Anthem failed to provide required mental health coverage despite state and federal parity laws mandating equal treatment of mental and physical health conditions.

Cause

The plaintiff claimed Anthem breached fiduciary duties under ERISA by using MCG “level of care guidelines” biased against residential treatment approvals. Anthem allegedly failed to disclose the use of these guidelines, used unqualified medical directors, and hired third-party reviewers with financial incentives to deny claims. The company allegedly violated the California Mental Health Parity Act and the Federal MHPAEA by denying medically necessary mental health care. The plaintiff also accused Anthem of misinterpreting the plan to maximize profits, ignoring appeal rights, and refusing to pay claims it knew were valid.

Injury

The denial allegedly deprived the plaintiff of necessary mental health treatment coverage for R.C., causing financial hardship. It also created emotional distress from the uncertainty and burden of paying for treatment out-of-pocket. The plaintiff claimed harm to the right to a fair and unbiased claim review.

Damages

The plaintiff sought payment of all owed mental health benefits with prejudgment interest. They requested restitution, disgorgement of profits, and reimbursement of attorneys’ fees and costs. Additional relief included an injunction against the use of current care guidelines and removal of Anthem as a fiduciary. The plaintiff also sought equitable remedies to restore them to the position they would be in if the benefits had been paid.

Key Arguments and Proceedings

Legal Representation

• Plaintiff(s): Dan C.

• Counsel for Plaintiff: David M. Lilienstein | Katie Joy Spielman

• Defendant(s): Anthem Blue Cross Life and Health Insurance Company (doing business as Anthem Blue Cross) | Directors Guild of America – Producer Health Plan | Directors Guild of America Inc.

• Counsel for Defendants: Chad R. Fuller | P. Jacob Kozaczuk | Jessamyn Elizabeth Vedro | Peter Yould | Kathleen Cahill Slaught | Ryan Robert Tikker | John Paul Moorhead | Lisa C. Demidovich

Claims

The complaint included:

1. Breach of fiduciary duties under ERISA.

2. Violation of the California Mental Health Parity Act.

3. Violation of the Federal MHPAEA.

4. Failure to follow plan terms and ERISA claim regulations.

5. Improper denial of benefits.

6. Use of unqualified or financially conflicted reviewers.

7. Equitable relief including injunctions and fiduciary removal.

Defense

The Directors Guild of America–Producer Health Plan denied any wrongdoing in its handling of the plaintiff’s claim and argued that the plaintiff was not entitled to damages, fees, or costs. It asserted that it had met all obligations under the Plan and that the complaint failed to state a valid cause of action. The defendant contended that ERISA barred any extra-contractual relief and that the claims were precluded by the Plan’s terms, the plaintiff’s non-compliance with those terms, and the introduction of new grounds or evidence outside the administrative process.

The defense further maintained that its determinations were supported by substantial evidence and were neither arbitrary nor capricious. It claimed the plaintiff suffered no injury, and that principles such as waiver, estoppel, unclean hands, consent, ratification, and unjust enrichment barred recovery. Additional arguments included failure to meet contractual conditions precedent, failure to mitigate damages, and justification for any alleged acts. The defendant reserved the right to raise further defenses as discovery progressed.

Judgement

On April 18, 2024, the U.S. District Court for the Central District of California entered judgment in favor of plaintiff Dan C. after a bench trial on January 3, 2024, overturning the Directors Guild of America–Producer Health Plan’s denial of health care benefits. The court ordered the defendant to pay the benefits owed plus prejudgment interest under 28 U.S.C. § 1961(a) and allowed the plaintiff to seek attorney’s fees and costs under ERISA.

Court Documents

Court documents are available for purchase upon request at Jurimatic@exlitem.com