Aetna Unlawfully Refused to Cover Inpatient Autism Treatment, Class Action Alleges

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A proposed class action alleges Aetna Life Insurance Company has violated federal law by refusing to cover inpatient treatment for certain mental health disorders, including autism spectrum disorder (ASD). 

According to the 23-page lawsuit, Aetna “treats mental health as less important than physical health,” and refused to reimburse the plaintiff’s costs for behavioral health services related to his son’s 2019 stay at a full-time, out-of-state residential treatment facility to help stabilize his ASD. A key contention in the complaint is Aetna’s self-imposed credentialing requirements for covered residential treatment facilities, which the plaintiff alleges the insurer fails to apply with parity with respect to medical/surgical facilities as required by federal law. 

“In other words, Aetna requires special accreditations for all residential facilities for mental health care but does not require the same of analogous medical and surgical treatment facilities,” the suit alleges. “Strikingly, similar accreditation is not required of any other medical facilities under the Aetna Plan.” 

The suit claims Aetna denied the plaintiff’s claim on the basis that the facility to which his son was admitted, which the lawsuit states is duly licensed by Utah to provide residential treatment services to young male clients, “is not accredited” by the Joint Commission, Committee on Accreditation of Rehabilitation Facilities, American Osteopathic Association’s Healthcare Facilities Accreditation Program or the Council on Accreditation, or credentialed by Aetna itself. 

Aetna’s coverage denial runs contrary to the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Parity Act), which requires that, when a group health plan provides both medical and surgical benefits and mental health or substance use disorder benefits, the plan or coverage will ensure that the limitations applied to mental health or substance abuse disorders are no more restrictive than the predominant limitations applied to all covered medical and surgical benefits, and that there are no separate treatment limitations applied only with respect to mental health or substance abuse disorders. 

From the complaint: 

“The Parity Act’s purpose was to end discrimination in the provision of insurance coverage for mental health treatment, as compared to medical and surgical services. While the Parity Act does not require health care plans to cover mental health services, if a plan chooses to cover mental health services, such coverage must be provided ‘at parity’ with medical/surgical benefits.” 

Per the suit, the plaintiff’s Aetna plan, as it pertains to the treatment of mental health disorders, covers expenses that include charges related to room and board at the semi-private room rate, and other services and supplies during a covered party’s stay in a hospital, psychiatric hospital or residential treatment facility. According to the complaint, Aetna, in denying certain coverage for inpatient mental health treatment at certain facilities, has imposed a set of internally developed criteria to determine which residential facilities are covered that’s “far more restrictive” than the standard it applies when determining coverage for medical and surgical services. The suit alleges Aetna does this “to minimize the number of claims accepted and thereby maximiz[e] Aetna’s own profits.” 

The lawsuit looks to represent all persons covered under a self-funded or fully insured Aetna health plan governed by the Employee Retirement Income Security Act who sought and were denied coverage for all or a portion of residential treatment for mental health disorders within the applicable statute of limitations, or whose requests for coverage for all or a portion of residential treatment for mental health disorders will be denied in the future. 

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