Lawsuit Investigation: Did Your Insurance Deny Your Substance Abuse Claim?

Attorneys working with ClassAction.org would like to speak to anyone who had their insurance company deny coverage for substance abuse treatment in the last two years.

Before attorneys can even consider taking legal action, they need to speak to people who had coverage for substance abuse treatment denied.

Insurance Denials: Why Do They Happen?

Insurance companies have a financial incentive to minimize the amount they pay out for medical claims. When it comes to treatment for substance abuse disorders, coverage is often denied because the insurance company deems that the care is not “medically necessary.”

Unfortunately, in many cases, the insurance company’s interpretation of what is “medically necessary” does not fall in line with the views of doctors and others in the healthcare community who care for addiction patients firsthand.

What Types of Denials Are Being Investigated?

Attorneys working with ClassAction.org are specifically investigating denied claims involving residential treatment, medication-assisted treatment and drug screenings. Specific information can be found below.

Residential Treatment

Patients who sought residential treatment for substance abuse may have been denied outright or told that in-patient care would only be covered for a certain length of time. Often, these time limits are arbitrary and do not allow for enough time for the patient to be treated successfully.

For those who were denied outright, the insurance company may have claimed that the patient needed to first start at an outpatient facility before moving to residential care. It’s believed some insurance companies may not be following criteria set by the American Society of Addiction Medicine in making these decisions.

Medication-Assisted Treatment

Insurance companies may also be placing certain limitations on patients undergoing medication-assisted treatment (MAT) for opioid addiction, such as methadone maintenance treatment. For instance, the insurance company may be putting an arbitrary time limit on how long the patient can receive MAT – even when the medical community operates under the belief that many opioid patients will need to be treated for life.

Some insurance companies may also be covering medications only in certain dosages or implementing restrictions that can put a patient’s life at risk. For instance, they may deny coverage for methadone for heroin addiction if the patient tests positive for marijuana.

Further, some insurance companies may be delaying approval for MAT or making the paperwork to receive coverage particularly difficult.   

Drug Tests

Treatment providers are required by law to administer drug tests and toxicology screens for patients who are being treated for opioid addiction with MAT. Whether the test is covered by insurance often depends on the type of screen being administered.

Unfortunately, attorneys suspect that some insurance companies are only approving coverage for cheaper – but far less accurate – drug tests that are considered by the medical community to be substandard.  

If a doctor requires a more expensive – and likely, more accurate – drug screen, the cost may be passed onto the patient.  

How a Lawsuit Can Help

A lawsuit could help patients get back the money they spent out of pocket, including the cost of drug screens and residential care, for addiction treatment. It could also require insurance companies to change the way they process claims. 

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