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W.P. v. Anthem Insurance Companies, Inc.

United States District Court, S.D. Indiana, Indianapolis Division

November 8, 2017

W. P., a minor by and through his parents and guardians KATHRYN PIERCE and CHESTER PIERCE, on behalf of themselves and similarly situated individuals,
v.
ANTHEM INSURANCE COMPANIES, INC., an Indiana corporation, Defendant. A.B., a minor by and through his parents and guardians MICHAEL BECK and JOANNE KEHOE, on behalf of themselves and similarly situated individuals, Plaintiffs,

          ENTRY ON MOTION FOR RECONSIDERATION

          TANYA WALTON PRATT, JUDGE

         This matter is before the Court on Plaintiff W.P. and his parents and guardians Kathryn Pierce and Chester Pierce, and A.B and his parents and guardians Michael Beck and Joanne Kehoe's (collectively “Plaintiffs”) Motion for Reconsideration or Certification for Interlocutory Review (Filing No. 77). On April 11, 2016, Defendant Anthem Insurance Companies, Inc. (“Anthem”) filed a Motion for Partial Judgment on the Pleadings (Filing No. 48). The Court granted Anthem's Motion for Partial Judgment on the Pleadings on February 15, 2017 (Filing No. 72). For reasons stated below, the Court grants the Motion for Reconsideration on the issue of Anthem's wrongful denial of Applied Behavioral Analysis (“ABA”) therapy hours unrelated to medical necessity, and as a result, grants in part and denies in part Anthem's Motion for Partial Judgment on the Pleadings. Having received a favorable ruling on their Motion for Reconsideration, the Court does not address Plaintiffs' Alternative Request for Certification for Interlocutory Review.

         I. BACKGROUND

         The facts of this case as stated in the February 15, 2017 Entry are not disputed and are only summarized in this Entry. In 2001, the Indiana General Assembly amended the Indiana Code, requiring individual and group health insurance policies to provide coverage for autism treatment. See Ind. Code § 27-8-14.2. This amendment is known as Indiana's Autism Mandate (“Autism Mandate” or “the statute”). The Autism Mandate provides:

(a) An accident and sickness insurance policy that is issued on a group basis must provide coverage for the treatment of an autism spectrum disorder of an insured. Coverage provided under this section is limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan. An insurer may not deny or refuse to issue coverage on, refuse to contract with, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage on an individual under an insurance policy solely because the individual is diagnosed with an autism spectrum disorder.
(b) The coverage required under this section may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally under the accident and sickness insurance policy.

Ind. Code Ann. § 27-8-14.2-4.

         On March 30, 2006, the Indiana Department of Insurance (“IDOI”), an agency charged with enforcing the Indiana Insurance Code, issued Bulletin 136 interpreting the Autism Mandate. See Ind. Ins. Bulletin 136, 2006 WL 1584562 (Mar. 30, 2006). Bulletin 136 states that an insurer has the right to “request an updated treatment plan not more than once every six (6) months from the treating physician to review medical necessity” and “[a]ny challenge to medical necessity will be viewed as reasonable only if the review is by a specialist in the treatment of [autism spectrum disorder].” Id. at 1, 3. Bulletin 136 also states that services to treat autism spectrum disorders “will be provided without interruption, as long as those services are consistent with the treatment plan and with medical necessity decisions.” Id. at 2. “Service exclusions contained in the insurance policy…that are inconsistent with the treatment plan will be considered invalid…”. Id.

         W.P. is a thirteen year-old who suffers from severe autism. W.P. has limited verbal skills, is unable to navigate stairs without assistance, and frequently exhibits repetitive behaviors including rocking, flapping his arms and hands, and heavy breathing. W.P.'s treating physician prescribed forty hours per week of ABA therapy to treat his autism. In February 2011, W.P. began receiving ABA therapy and his parents observed almost immediate improvements in his ability to walk, use words, and respond appropriately to prompts. W.P.'s repetitive behaviors also decreased.

         W.P. is the beneficiary of a health insurance plan (“the Plan”) sponsored by his father's employer. Anthem is the insurer and claims administrator for the Plan. Anthem initially covered W.P.'s forty hours per week of ABA therapy but, in July 2013, Anthem reduced the number of covered ABA therapy hours for W.P. to twenty-five hours per week. In July 2014, Anthem further reduced the number of covered hours to twenty hours per week. On April 9, 2015, Plaintiffs filed this putative class action asserting that Anthem's policy and practice of limiting coverage for ABA therapy for school-aged children with autism violates ERISA because it fails to comply with Indiana's Autism Mandate, as well as federal law.

         II. LEGAL STANDARDS

         Motions to reconsider serve a limited function, to be used “where the Court has patently misunderstood a party, or has made a decision outside the adversarial issues presented to the Court by the parties, or has made an error not of reasoning but of apprehension.” Davis v. Carmel Clay Sch., 286 F.R.D. 411, 412 (S.D. Ind. 2012) (quoting Bank of Waunakee v. Rochester Cheese Sales, Inc., 906 F.2d 1185, 1191 (7th Cir. 1990)) (additional quotations omitted). A court may grant a motion to reconsider where a movant demonstrates a manifest error of law or fact. In re Prince, 85 F.3d 314, 324 (7th Cir. 1996). A motion to reconsider is not an occasion to make new arguments. Granite State Ins. Co. v. Degerlia, 925 F.2d 189, 192 n.7 (7th Cir. 1991).

         Like a Rule 12(b)(6) motion, the court will grant a Rule 12(c) motion only if “it appears beyond doubt that the plaintiff cannot prove any facts that would support his claim for relief.” N. Ind. Gun & Outdoor Shows, Inc. v. City of S. Bend, 163 F.3d 449, 452 (7th Cir. 1998) (quoting Craigs, Inc. v. Gen. Elec. Capital Corp., 12 F.3d 686, 688 (7th Cir. 1993)). The factual allegations in the complaint are viewed in a light most favorable to the non-moving party; however, the court is “not obliged to ignore any facts set forth in the complaint that undermine the plaintiff's claim or to assign any weight to unsupported conclusions of law.” Id. (quoting R.J.R. Serv., Inc. v. Aetna Cas. & Sur. Co., 895 F.2d 279, 281 (7th Cir. 1989)). “As the title of the rule implies, Rule 12(c) permits a judgment based on the pleadings alone. . . . The pleadings include the complaint, the answer, and any written instruments attached as exhibits.” Id. (internal citations omitted).

         III. ...


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