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Reid v. BCBSM, Inc.

United States District Court, D. Minnesota

November 21, 2013

Tracy L. Reid, individually and on behalf of M.A.R., Plaintiff,
v.
BCBSM, Inc., HealthPartners Insurance Company, Minnesota Department of Commerce, Michael Rothman in his capacity as Commissioner of the Minnesota Department of Commerce, and Blue Cross and Blue Shield of Minnesota Medical Plan, Group No. 4G175-00, Defendants

Page 950

Tracy L. Reid, Minneapolis, Minnesota, Plaintiff Pro se.

Joel A. Mintzer, Robins Kaplan Miller & Ciresi LLP, Minneapolis, Minnesota, for Defendants BCBSM, Inc. and Blue Cross and Blue Shield of Minnesota Medical Plan, Group No. 4G175-00.

Gregory R. Merz, Ashley M. Bennett Ewald, Gray Plant Mooty Mooty & Bennett, PA, Minneapolis, Minnesota, for Defendant HealthPartners Insurance Company.

Oliver J. Larson, John R. Mule, Minnesota Attorney General's Office, Saint Paul, Minnesota, for Defendants Minnesota Department of Commerce and Michael Rothman.

OPINION

Page 951

MEMORANDUM OPINION AND ORDER

RICHARD H. KYLE, United States District Judge.

INTRODUCTION

Plaintiff Tracy Reid commenced this action on behalf of herself and M.A.R., her seven-year-old son who has autism spectrum disorder (" ASD" ),[1] after her previous and current health insurers, Defendants HealthPartners Insurance Company (" HealthPartners" ) and BCBSM, Inc. (" Blue Cross" [2]) respectively, excluded coverage of certain intensive behavioral therapies used to treat her son's ASD. Reid asserts Defendants Blue Cross, HealthPartners, the Minnesota Department of Commerce (" MNDC" ), and MNDC's Commissioner, Michael Rothman, violated the Americans with Disabilities Act (" ADA" ), Employee Retirement Income Security Act of 1974 (" ERISA" ), and several other statutes. All Defendants now move to dismiss Reid's claims; for the reasons set forth below, MNDC and Rothman's Motion and HealthPartners' Motion will both be granted and Blue Cross's Motion will be granted in part and denied in part.

BACKGROUND

The following facts are alleged in Reid's Second Amended Complaint:[3]

Plaintiff's son, M.A.R., was identified as developmentally delayed by his first birthday. He began receiving physical therapy to address his delayed walking, speech, and motor skills, and special-education services to address his delayed cognitive development. (2d Am. Compl. ¶ ¶ 9-11.) At age two, he was referred to the Alexander Center for treatment by a developmental pediatrician, a physical therapist, an occupational therapist, and a speech therapist, all of which was covered by Reid's health-insurance provider, HealthPartners. (Id. ¶ 12.) At that time, M.A.R. exhibited multiple violent tantrums daily, aggressive behavior toward his peers and school staff, and severe social limitations. (Id. ¶ 13.) M.A.R. was diagnosed with ASD in June 2008 and referred to the Minnesota Early Autism Project (" MEAP" ) for intensive behavioral therapy [4] and other treatment,

Page 952

which took up to forty hours per week. (Id. ¶ ¶ 16-17.) Reid alleges intensive behavioral therapy is the most effective treatment for children with ASD and relies upon numerous medical studies supporting this proposition. (Id. ¶ ¶ 27-34.) For M.A.R., it greatly reduced his violent tantrums and aggressive behavior, boosted his IQ, and allowed him to be integrated 100% of the time with his non-disabled peers at school. (Id. ¶ ¶ 50-54.) By June 2012, M.A.R. required only limited assistance and consulting from MEAP.

Reid's health-insurance policy with HealthPartners specifically excluded coverage of " Intensive behavioral therapy treatment programs for the treatment of autism spectrum disorders, including ABA, IEIBT and Lovaas." (Id. ¶ 61.) When Reid sought benefits for M.A.R.'s intensive behavioral therapy, HealthPartners denied her claim, relying upon this coverage exclusion. She appealed the decision, and HealthPartners affirmed its denial, asserting M.A.R.'s intensive behavioral therapy constituted IEIBT, and therefore was not covered. HealthPartners' final denial letter referred Reid to covered providers for ASD treatment, including the Alexander Center, the Fraser Center, and the Associated Clinic of Psychology. But Reid had already consulted with the Alexander Center, which referred her to MEAP, and the Fraser Center and Associated Clinic of Psychology did not offer treatment appropriate for M.A.R. After exhausting the internal appeals procedure, Reid sought review from MAXIMUS, an independent review organization that contracted with MNDC and the Minnesota Department of Health to review insurance claims. In February 2011, MAXIMUS affirmed HealthPartners' denial of coverage based on her plan's exclusion of such intensive therapy for ASD. Reid filed a complaint with the Minnesota Department of Human Rights, which was ultimately dismissed.

In January 2012, Reid--by that time self-employed--contracted with Defendant Blue Cross for a new health insurance plan for herself and M.A.R., which did not exclude intensive behavioral therapy. Nonetheless, Blue Cross denied her claim for benefits in February, concluding M.A.R.'s therapy was not " ...


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