In what could prove to be a landmark case, a federal judge in Northern California ruled this week that a subsidiary of Minnetonka-based UnitedHealth Group violated its responsibilities to patients with mental health and substance use disorder needs.
The class-action lawsuit against United Behavioral Health represents people covered by United plans between 2011 and 2017 and who were denied coverage for treatment of behavioral health and substance use problems. The suit accused the company of limiting coverage to acute and immediate behavioral health and substance use needs, and refusing to pay for treatment of underlying, longer-term conditions.
At every level of care, "there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members' underlying conditions," U.S. Chief Magistrate Judge Joseph C. Spero wrote in his 106-page decision. The result is a "significantly narrower scope of coverage than is consistent with generally accepted standards of care."
Spero said the reason was clear: profits. The company's coverage decisions were based "as much or more on its own bottom line as on the interests of the plan members, to whom it owes a fiduciary duty," he wrote.
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The problem is that "these issues are not merely acute," said D. Brian Hufford, one of the attorneys representing the plaintiffs, in a phone interview. "The acute is a result of the underlying chronic condition and unless you focus on the chronic condition, you're really never going to be able to help that patient fully address their issues."
In other words, it would be like an insurance company agreeing to cover a patient's heart attack, but not the treatment for the high cholesterol or high blood pressure that caused it.
Hufford said behavioral health is uniquely subject to these kinds of denials of coverage because complicated, chronic conditions leave room for the insurance companies to use discretion about when to cover treatment.
UnitedHealth did not respond to a request for comment but is quoted in other news outlets as saying, "We remain committed to providing our members with access to the right care for the treatment of mental health conditions and substance use disorders."
Federal and state parity laws are supposed to ensure that behavioral health needs are covered in the same way physical health needs are, but many say that is not the case, especially when the need is not acute. There are lawsuits pending against several other companies.
The company could eventually appeal the decision.
If you feel you were improperly denied coverage for behavioral health care by United or another insurance company, we would like to hear from you: firstname.lastname@example.org
This reporting is part of Call to Mind, MPR initiative to foster new conversations about mental health.