When an HMO Provides the Same Limitations for Physical as Mental Problems the Limitations are Enforceable

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Plaintiff Suzanne Stone had an employer-provided health care plan (the “Plan”) governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001-1461, and administered by Defendant U.S. Behavioral Health Plan, California, dba OptumHealth Behavioral Solutions of California (“Optum”). The Plan excluded coverage for any out-of-state treatment, except for emergency or urgently needed services.

ZALMA OPINION

HMO’s exist to allow people to buy inexpensive health insurance and can do so by limiting the availability of the coverage. The treatment needed by GS could be provided in the state of California and would have been covered by the plan. However, the Plaintiff decided to use the facility in Colorado that was believed to be better for GS than what is available in California. She was told there would be no coverage and ignored the fact and decided to sue for coverages clearly and unambiguously excluded. She failed.