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A.F. v. Providence Health Plan

United States District Court, D. Oregon

August 8, 2014

A.F., by and through his parents and guardians, Brenna Legaard and Scott Fournier; and A.P., by and through his parents and guardians, Lucia Alonso and Luis Partida, and on behalf of similarly situated individuals, Plaintiffs,
v.
PROVIDENCE HEALTH PLAN, Defendant

Page 1299

[Copyrighted Material Omitted]

Page 1300

For Plaintiffs: Keith S. Dubanevich, Joshua L. Ross, Nadine A. Gartner, STOLL STOLL BERNE LOKTING & SHLACHTER, P.C., Portland, OR; Megan E. Glor, MEGAN E. GLOR, ATTORNEYS AT LAW P.C., Portland, OR.

For Defendant: William F. Gary, Arden J. Olson, Aaron Landau, HARRANG LONG GARY RUDNICK, P.C., Eugene, OR; Aaron T. Bals, HARRANG LONG GARY RUDNICK, P.C., Portland, OR.

Page 1301

OPINION AND ORDER

Michael H. Simon, United States District Judge.

Autism Spectrum Disorder is a pervasive developmental disorder that begins to appear during early childhood and is characterized by impairments in communication and social skills, severely restricted interests, and repetitive behavior. Applied Behavior Analysis (" ABA" ) is an early intensive behavioral interaction health service that helps people with autism to perform social, motor, verbal, behavior, and reasoning functions that they would not otherwise be able to do. Plaintiffs A.F. and A.P. (collectively " Plaintiffs" ) are both covered as dependent-beneficiaries under group health insurance plans issued by Defendant Providence Health Plan (" Providence" ). A.F. and A.P. were denied coverage of ABA therapy by Providence--both initially and on appeal--based on Providence's " Developmental Disability Exclusion."

Plaintiffs bring this class action lawsuit, alleging that Providence's denial of ABA therapy on the basis of its Developmental Disability Exclusion violates the Employee Retirement Income Security Act (" ERISA" ), 29 U.S.C. § 1001, et seq.; the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (" Federal Parity Act" ), 29 U.S.C. § 1185a; and two Oregon state laws, Or. Rev. Stat. § § 743A.168 and 743A.190. Plaintiffs moved for class certification, which the Court granted. The parties have agreed that the Court should treat their pending motions as cross motions for partial summary judgment. For the reasons that follow, the court grants partial summary judgment for Plaintiffs and denies Defendant's cross motion. Providence's Developmental Disability Exclusion violates both the Federal Parity Act and Oregon law and is therefore prohibited under ERISA.

STANDARDS

A. De Novo Review

Judicial review of an ERISA-governed insurance policy that grants the insurer discretion to determine a claimant's eligibility for benefits is ordinarily reviewed for " abuse of discretion." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). When a court reviews questions of statutory interpretation, however, it owes no deference to the insurer's decision and reviews legal questions de novo. Long v. Flying Tiger Line, Inc. Fixed Pension Plan for Pilots, 994 F.2d 692, 694 (9th Cir. 1993). The issues presented in the pending motions are questions of statutory interpretation.

B. Motion for Summary Judgment

A party is entitled to summary judgment if the " movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(a). The moving party has the burden of establishing the absence of a genuine dispute of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). The court must view the evidence in the light most favorable to the non-movant and draw all reasonable inferences in the non-movant's favor. Clicks Billiards Inc. v. Sixshooters Inc., 251 F.3d 1252, 1257 (9th Cir. 2001). Although " [c]redibility determinations, the weighing of the evidence, and the drawing of legitimate inferences from the facts are jury functions, not those of a ...


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