Mental Health Treatment Wrongly Denied by Insurance Giant
In a landmark ruling, a federal court held Tuesday that health insurance giant United Behavioral Health (UBH), which serves over 60 million members and is owned by UnitedHealth Group, used flawed internal guidelines to unlawfully deny beneficiaries access to mental health and substance use treatment in an effort to cut costs. The ruling marks a validation for patients and providers who have long raised concerns that health plans were not fulfilling the requirements set forth in the Mental Health Parity and Addiction Equity Act of 2008, which established parity between the coverage of behavioral health and medical/surgical benefits.
According to a press release from Globe Newswire, the federal court found that, to promote its own bottom line, UBH denied claims based on internally developed medical necessity criteria that were far more restrictive than generally accepted standards for behavioral health care. Other concerns the court noted included:
- Internal criteria that was skewed to cover “acute” treatment, while ignoring underlying chronic mental health conditions that required ongoing care;
- UBH’s lack of coverage criteria for children and adolescents;
- UBH having guidelines that were inconsistent with the American Society of Addiction Medicine (ASAM) criteria, which insurers must use in Connecticut, Illinois, and Rhode Island;
- UBH also failed to apply Texas-mandated substance use criteria at least for a limited period of time.
The release goes on to explain that while the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires parity for mental health and substance use benefits, insurers are permitted to evaluate claims for medical necessity. However, by using flawed medical necessity criteria, insurers can circumvent parity in favor of financial considerations and prevent patients from receiving the type and amount of care they actually require.
“For far too long, patients and their families have been stretched to the breaking point, both financially and emotionally, as they battle with insurers for the mental health coverage promised by their health plans,” said Psych-Appeal’s Meiram Bendat, co-counsel for the plaintiffs in the class action suit. “Now a court has ruled that denying coverage based on defective medical necessity criteria is illegal.”
The National Council continues to advocate for stronger parity enforcement and has been active in supporting state parity efforts including the Kennedy Forum’s “Don’t Deny Me Campaign” and the American Psychiatric Association’s model state parity implementation legislation.