A proposed class action claims United Behavioral Health (UBH) has unlawfully denied coverage for certain mental health and substance use disorder treatments based on overly restrictive criteria that fail to align with generally accepted standards.
According to the 43-page case, UBH has deliberately developed policies designed to reduce the number and value of approved claims rather than fulfill its fiduciary duty to act in the best interests of the participants and beneficiaries of the plans it administers.
“The UBH policies at issue in this case all disregard or directly flout the terms of the Plaintiffs’ Plans, and were developed to serve UBH’s interests and those of its plan sponsor customers rather than those of the plan members,” the complaint contests. “As a result, the policies all breach the fiduciary duties UBH owes to all ERISA [Employee Retirement Income Security Act] plan members, including Plaintiffs.”
The plaintiffs, most of whom filed their claims under pseudonyms, are six individuals whose requests for coverage for mental health or substance use disorder services were allegedly denied based on overly restrictive standards. Moreover, the plaintiffs allege UBH unlawfully denied their coverage requests for residential treatment services, including certain services that UBH had determined were medically necessary, because the defendant insisted that their residential treatment was unnecessary.
According to the suit, the plaintiffs’ respective health plans offered coverage for treatment of sickness, injury, mental illness and substance use disorders, including residential treatment. The plans also offered coverage for partial hospitalization (PHP) services and intensive outpatient (IOP) services for mental health and substance use disorder treatment, the case relays.
Per the filing, coverage for certain services under the plaintiffs’ plans is determined by assessing, among other factors, whether those services are consistent with generally accepted standards of care. The suit notes that although the plaintiffs’ plans differ slightly in their wording, they all define such standards in the context of mental health and substance use disorder services as those that “have achieved widespread acceptance among behavioral health professionals.”
The lawsuit alleges, however, that UBH has developed level of care guidelines that are “much more restrictive” than generally accepted standards of care, and has, in order to advance its own financial interests, improperly denied participants’ and beneficiaries’ coverage claims for services that were medically necessary. According to the suit, UBH has been the subject of prior litigation in which a judge found that the 2011 through 2017 editions of the company’s level of care guidelines were unnecessarily restrictive and that UBH had breached its fiduciary duties and abused its discretion by developing the guidelines and using them as the basis to deny coverage to plan participants and beneficiaries. The case alleges UBH’s 2018 and 2019 level of care guidelines at issue are plagued by the same problems and provide for narrower coverage than is consistent with the generally accepted standards of care.
The lawsuit goes on to claim that UBH maintains a policy whereby it bundles facility-based behavioral health services in a manner that results in an all-or-nothing approach to coverage for services at inpatient, residential treatment, partial hospitalization and intensive outpatient levels of care. The suit more specifically claims that because UBH reimburses the cost of services rendered at behavioral health facilities at a “single day rate,” coverage for services that UBH would have deemed medically necessary is denied when UBH determines that facility-based treatment is not covered at the requested level of care.
“In other words, UBH relies on its reimbursement policy to deny claims for facility-based services on a ‘single day,’ bundled basis, rather than determining whether to approve coverage for any of the component services necessarily provided as part of the facility-based program,” the complaint alleges. “UBH does so even if the component services are otherwise covered under the member’s Plan and even where, as here, UBH has already determined that services necessarily included within the bundled rate are medically necessary for the member.”
According to the suit, UBH’s decision to “categorically refuse” to un-bundle services provided at a behavioral health facility, despite admitting in many cases that some of the services are medically necessary, is a violation of the defendant’s fiduciary responsibility to discharge its duties in the best interests of plan participants and beneficiaries.
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