Last week, a federal judge ruled
that United Behavioral Health, UnitedHealth Group's behavioral health insurer, breached its duty to patients and made arbitrary and capricious coverage denials by using restrictive coverage determination policies that deviated from clinical guidelines.
The ruling stems from a class action lawsuit brought on behalf of approximately 50,000 patients who were denied coverage for residential mental health and substance use disorder treatment. Under federal law, self-insured health plans are obligated to administer health plan benefits “solely in the interest of the participants and beneficiaries . . . [and with] care, skill, prudence, and diligence.”
The court found that determining coverage using criteria that deviated from established standards of care violated the fiduciary duty that was owed to patients.
At issue in the recently decided case, Wit v. United Behavioral Health
, were internal United Behavioral Health coverage determination policies that were significantly more restrictive than the standard of care. These guidelines, according to plaintiffs, focused on acute symptoms rather than chronic conditions, inappropriately limiting coverage to treatment that would alleviate symptoms instead of treatment that would address an individual’s underlying condition.
This “overemphasis on acuity,” the court ruled, resulted in inappropriate denials of coverage for patients and violated federal law. Although federal and state law generally require health plans to provide mental health and substance use disorder benefits at levels equal to other medical or surgical benefits, patients continue to struggle to obtain coverage for treatment of mental health and substance use disorders. This decision, if upheld on appeal, could provide a legal avenue for patients to ensure that they receive adequate coverage for treatment of mental health and substance use disorders.