10.  Under the terms of the plan, Anthem is required to authorize coverage for  “covered services.” The plan’s definition of “covered services” is services, supplies or  treatment as described in this Benefit Booklet which are performed, prescribed, directed  or authorized by a Provider. To be a Covered Service, the service, supply or treatment  must be:  Medically Necessary or otherwise specifically included as a benefit under the  Plan.  Within the scope of the license of the Provider performing the service.  Rendered while coverage under the Plan is in force.  Not Experimental/Investigative or otherwise excluded or limited by this Benefit  Booklet, or any amendment or rider thereto. (Att. A, p. M-94).   11.  Medically necessary and medical necessity are, in turn, defined as “[a]n  intervention that is or will be provided for the diagnosis, evaluation and treatment of a  condition, illness, disease or injury and that is determined by [Anthem] to be:  Medically appropriate for and consistent with the symptoms and proper  diagnosis or treatment of the Member’s condition, illness, disease or injury;  Obtained from a Provider;  Provided in accordance with applicable medical and/or professional standards;  Known to be effective, as proven by scientific evidence, in materially improving  health outcomes;  4  The most appropriate supply, setting or level of service that can safely be  provided to the Member and which cannot be omitted consistent with recognized  professional standards of care (which, in the case of hospitalization, also means  that safe and adequate care could not be obtained in a less comprehensive  setting);  Cost-effective compared to alternative interventions, including no intervention.  Cost Effective does not always mean lowest cost. It does mean that as to the  diagnosis or treatment of the Member’s illness, injury or disease, the service is:  (1) not more costly than an alternative service or sequence of services that is  medically appropriate, or (2) the service is performed in the least costly setting  that is medically appropriate;  Not Experimental/Investigative;  Not primarily for the convenience of the Member, the Member’s family or the  Provider.  Not otherwise subject to an exclusion under this Benefit Booklet. (Id., M-96).   12.  A Provider, in turn, is “[a] duly licensed person or facility that provides  services within the scope of an applicable license and is a person or facility that the Plan  approves.” This includes certified nurse midwives, home health care agencies,  alcoholism treatment facilities, home infusion facilities, licensed professional  counselors,  occupational  therapists,  independent  social  workers,  professional  counselors, retail health clinics, skilled nursing facilities, and social workers. (Id., M- 98-101).   13.  The plan specifically covers behavioral health benefits. (Id. at M-9, M- 11).   14.  The plan specifically excludes “[c]are provided or billed by residential  treatment centers or facilities, unless those centers or facilities are required to be  covered under state law.” (Id. at M-46).   15.  Plaintiff’s daughter, who is covered under her mother’s plan and is thus  entitled to receive health insurance coverage based on the same plan language as her  5  mother’s, has struggled for years with mental health issues such as eating disorder,  borderline personality and attention deficit/hyperactivity disorder.  In July 2014, at the  recommendation of her therapist, plaintiff’s daughter was sent to Vista Sage, a Utah- based licensed residential treatment center that specializes in the therapeutic treatment  of adolescent women with comparable diagnoses.    16.  While at Vista, T.N. received medically necessary mental health services,  including psychiatric evaluation, individual therapy, group therapy and family therapy,  all of which would have been authorized for coverage by Anthem if they had been  delivered in another type of mental health setting.    17.  Plaintiff paid $58,220 for services rendered at Vista from July through  December 2014 and sought coverage. Her claims were denied by Anthem originally and  on the first and second level appeals. In all cases, Anthem relied on the residential  treatment exclusion discussed above. In no case did Anthem challenge the medical  necessity of the services. The final denial was dated September 21, 2016.   18.  Anthem’s residential treatment center exclusion violates the federal Parity  Act. The Parity Act was “designed to end discrimination in the provision of coverage for  mental health and substance use disorders as compared to medical and surgical  conditions in employer-sponsored group health plans and health insurance coverage  offered in connection with group health plans.” American Psychiatric Ass’n v. Anthem  Health Plans, 50 F. Supp.3d 157, 160 (D. Conn. 2014).  In relevant part, the Parity Act  states:  In the case of a group health plan (or health insurance coverage offered in  connection with such a plan) that provides both medical and surgical benefits and  mental health or substance use disorder benefits, such plan or coverage shall  ensure that—  6  (ii) the treatment limitations applicable to such mental health or substance  use disorder benefits are no more restrictive than the predominant  treatment limitations applied to substantially all medical and surgical  benefits covered by the plan (or coverage) and there are no separate  treatment limitations that are applicable only with respect to mental  health or substance use disorder benefits.   29 U.S.C. § 1185a(a)(3)(A)(ii).   19.  The issue as to whether an insurer may lawfully deny all mental health  treatment rendered at a residential treatment center was considered in Joseph & Gail F.  v. Sinclair Servs. Co., 2016 U.S. Dist. LEXIS 8644 (D. Utah Jan. 22, 2016). There the  court found that such a blanket exclusion violated the Act:  To be sure, the Parity Act does not require plans to provide mental health or  substance use disorder benefits at all. But once a plan does provide such benefits,  the plan must do so on a level that is on par with the benefits it provides for  medical and surgical benefits. And once provided, the Parity Act prohibits  imposing treatment limitations applicable only to mental health benefits.  Further, although the Administrator argues that the exclusion applies across the  board, there is no evidence to suggest that coverage for residential treatment  would have been available for medical or surgical conditions but for the  exclusion. Without evidence to that effect, the Administrator's argument that it  would have also denied residential treatment benefits for medical or surgical  conditions under the exclusion is illusory.  The court concludes that the Plus Plan's residential treatment exclusion violates  the Parity Act because the exclusion is a "separate treatment limitation[] that [is]  applicable only with respect to mental health . . . benefits."  Id. at *51.   20.  Anthem’s plan violates the Parity Act in exactly the same manner. Its  blanket exclusion for services rendered at wilderness treatment programs is a separate  treatment limitation applicable only to mental health benefits and thus violative of the  Parity Act.   21.  Plaintiff’s ERISA-governed health plan incorporates the protection of the  Parity Act through 29 U.S.C. § 1185a(a)(3)(A).  7  22.  Plaintiff brings this lawsuit under Fed. R. Civ. P. 23(b)(2) on her own  behalf and on behalf of the following class:  All persons who are covered under any  ERISA-governed contract or plan of health benefits administered, underwritten or  insured by Anthem that provides coverage for behavioral or mental health care but  that categorically excludes coverage for behavioral health services rendered at  residential treatment centers.   23.  Plaintiff brings this lawsuit under Fed. R. Civ. P. 23(b)(3) on her own  behalf and on behalf of the following subclass:  All persons who are covered under any  ERISA-governed contract or plan of health benefits administered, underwritten or  insured by Anthem that provides coverage for behavioral or mental health care and  whose claims for coverage for behavioral health services rendered at residential  treatment centers were denied because the contract or plan excluded such coverage.    24.  Membership in the proposed class and subclass is so numerous that  individual joinder of all class members is impracticable except by means of a class  action.  The disposition of the claims in a class action will benefit both the parties and  the Court.  The exact number of class members can be readily determined through  discovery of Anthem’s business records.     25.  Plaintiff’s claims are typical of all other class members.  All class members’  claims are unified, as all are subject to Anthem’s residential treatment center exclusion,  which violates the protections of the federal Parity Act.    26.  Plaintiff’s interests are coincident with, and not antagonistic to, those of  the other members of the class and the sub-class. Plaintiff is a member of both the class  and the subclass.  8   27.  Plaintiff will adequately represent both the class and the subclass because  she has interests in common with the proposed class members and plaintiff has retained  attorneys who are experienced in class action litigation.   28.  There is a well-defined community of interest in the questions of law and  fact involving and affecting the class and the sub-class to be represented by plaintiff.  Common questions of law and/or fact predominate over any questions affecting only  individual members of the class.  Common questions include, but are not limited to, the  following:  a. Whether Anthem’s blanket exclusion of coverage for services at residential  treatment centers violate the Parity Act?   b. If Anthem’s acts violate the Parity Act, what is the appropriate remedy?  c. What is the appropriate measure of relief?   29.  The prosecution of separate actions by individual members of the class  and the sub-class would create a risk of:  a. Inconsistent or varying adjudications concerning individual members of  the class and/or subclass that would establish incompatible standards of  conduct for Anthem opposing the class; and  b. Adjudication with respect to individual members of the class and sub-class  that would, as a practical matter, be dispositive of the interests of other  members not parties to such adjudications, and/or substantially impair or  impede the ability of other non-party class members to protect such  individual interests.   30.  The class action method is appropriate for the fair and efficient  prosecution of this action.    31.  Individual litigation of all claims that might be asserted by all members of  the class and the sub-class would produce such a multiplicity of cases that the judicial  system, having jurisdiction of the claims, would remain congested for years.  Class  9  treatment, by contrast, provides manageable judicial treatment calculated to bring a  rapid conclusion to all litigation of all claims arising out of the conduct of Anthem.   32.  The certification of the above class and subclass would allow litigation of  claims that, in view of the expense of the litigation, may be an insufficient amount to  support separate actions.  A.  Coverage  