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Conn. Judge Revives Aetna Physical Therapy Coverage Fight

March 17, 2022

By Kellie Mejdrich | Law360 (March 15, 2022) -- A federal judge in Connecticut on Tuesday revived a proposed class action alleging Aetna Life Insurance Co. violated federal benefits laws when it denied coverage for a Yale health plan beneficiary's physical therapy using an overly restrictive definition of medical necessity for treatment.

U.S. District Judge Michael P. Shea ordered the case reopened and gave plaintiff Dennis Curtis another chance to amend his complaint. Curtis, a member of Yale University's health plan, originally sued in 2019, alleging Aetna violated the Employee Retirement Income Security Act when it denied coverage for physical therapy treatments that his doctor said were necessary to recover from a neurological condition and various surgeries. Yale was not named as a party to the suit.

"After reviewing Curtis' proposed amendment, I find that it is sufficient to state a plausible claim for wrongful denial of benefits under ERISA," Judge Shea wrote.

The judge dismissed the case in March 2021 after concluding that Curtis couldn't prove the physical therapy treatments were covered under his plan.

Curtis filed a motion to amend his complaint the same month his complaint was dismissed. In his motion, Curtis told the court that he could present plan documents that showed short-term rehabilitative services including physical therapy were eligible for coverage.

Aetna argued in a brief filed in April 2021 that Judge Shea should deny the motion to amend the complaint because it was inexcusably late, delayed for tactical reasons and ultimately wouldn't change the outcome of the case.

The insurer said in its filing that Curtis was "seeking, post-judgment, to make lemonade out of a lemon."

"Curtis certainly knew why his doctors were prescribing physical therapy for him since 2016, and he affirmatively chose to allege that such services were intended to maintain, not improve, his physical function," Aetna said. "He did so in furtherance of pursuing a nationwide class action alleging that Aetna routinely denied claims for various types of therapy that were intended to maintain function rather than improve it."

But Judge Shea said in Tuesday's order reopening the case that the proposed amendment from Curtis, adding language from plan documents asserting that physical therapy was among the health services eligible for coverage, would cure deficiencies that previously doomed his case.

In addition to granting Curtis' motion to alter the judgment and for leave to amend the complaint, the judge rejected Aetna's arguments that Curtis took too long to amend the complaint and that the omissions from earlier versions of the complaint were made in bad faith.

"Curtis has plausibly alleged that he sought habilitation physical therapy services under the Yale plan and that he was wrongfully denied that benefit," Judge Shea said.

Curtis, who sued on behalf of a proposed class of beneficiaries insured by the plan, claimed Aetna had wrongly denied him physical therapy benefits by relying on prohibitive policy definitions Aetna provided for the Yale plan's outline of covered treatments. In his original complaint, Curtis said Aetna had relied on internal policy bulletins that limited the definition of medical necessity to deny his claim, but the bulletins weren't actually part of the plans.

Counsel for and representatives of both parties did not immediately respond to requests for comment Tuesday.

Curtis is represented by Steven Bloch, David S. Golub and Sarah A. Ricciardi of Silver Golub & Teitell LLP.

Aetna is represented by Patrick W. Begos and Theodore J. Tucci of Robinson & Cole LLP.

The case is Curtis v. Aetna Life Insurance Co., case number 3:19-cv-01579, in the U.S. District Court for the District of Connecticut.

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