Court Rules Insurance Company Illegally Denied Mental Health Care

The U.S. District Court for the Northern District of California found that United Behavioral Health (UBH), a subsidiary of UnitedHealth Group, intentionally denied mental health and substance abuse coverage for tens of thousands of patients, including children. The criteria placed emphasis on treating patients in crisis while denying claims for ongoing and preventative care. According to the court, the insurance company used a flawed set of criteria for determining the necessity of treatment in order to keep their own costs down.

UBH’s Flawed Criteria Left Thousands Without Care

As mentioned, UBH deliberately adopted criteria that was used to deny claims for more than 50,000 mental health patients. The criteria favored claims for acute and crisis-level conditions while denying claims for ongoing care and chronic conditions, such as depression, anxiety, eating disorders and addiction. In other words, the insurer would pay for care to stabilize a patient in crisis but would not pay to treat the underlying cause of the crisis.

How did the insurance company get away with it? Insurance companies are permitted to deny claims that are medically unnecessary. However, there is a set of guidelines they must follow to make that decision. The court found that the insurer misled regulators about their criteria and made it seem like they were following mandated guidelines.

Mental Health Insurance Coverage and the Law

According to the Patient Protection and Affordable Care Act, all insurers are required to offer mental health and addiction services coverage. Additionally, coverage for mental health services cannot be more restrictive than coverage for medical and surgical services.

The State of Mental Health Care in the United States

Sadly, many people with a diagnosed mental illness do not have access to treatment. There are several causes, including lack of insurance coverage and lack of access to coverage. As of 2019, Mental Health America reported that more than 12% of people with mental illness had no insurance coverage. What’s more, having coverage does not guarantee treatment. One out of five people who sought treatment did not get it due to denied insurance claims, financial difficulty and a shortage of treatment providers.

Mental illness accounts for one-third of adult disabilities in the world. As it stands, the available treatment is failing to meet the needs of the mental health crisis in the country. Rulings like this play a role in ensuring more people have access to care, but we have a long way to go.

~ Here's to Your Health and Wellness

Other Sources:

http://alert.psychnews.org/2019/03/ubh-found-to-have-wrongfully-denied.html

https://www.nytimes.com/2019/03/05/health/unitedhealth-mental-health-parity.html