Who can challenge an ERISA benefit denial? Does a physician have standing to challenge the denial of a patient’s coverage? It depends.
Here’s the case of American Psychiatric Association v. Anthem Health Plans, 821 F. 3d 352 (2nd Cir. 2016)(Physicians and physician associations lacked standing to sue health plans under ERISA.)
FACTS: The Mental Health Parity and Addiction Equity Act (MHP) requires health plans to provide the same coverage for mental health conditions as covered for physical conditions. Treatment limitations for mental health and substance cannot be more restrictive than restrictions covering medical and surgical benefits. Psychiatrists brought ERISA claims contending that four insurers imposed unnecessary administrative burdens on the psychiatrists, and reimbursed them at a lower rate than non-psychiatric physicians who provided comparable medical services.
TRIAL COURT HELD: Physicians and associations lacked legal standing to sue under ERISA, and MHP did not create a statutory cause of action.
SECOND CIRCUIT HELD: AFFIRMED. Psychiatrists lacked standing to sue under ERISA.
NOTE: The result regarding standing to assert an ERISA claim may have been different if the physicians had obtained an assignment of claims made in exchange for consideration (healthcare services provided). The physicians here did not do that.