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Class action suit against UnitedHealthcare examines how parity is applied

June 2, 2014
by Julie Miller
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D. Brian Hufford

Those who go to bat with health insurers on behalf of their clients might need to take a closer look at how care standards are applied in coverage policies, according to attorney D. Brian Hufford, partner in the New York office of Zuckerman Spaeder LLP. Parity in the context of insurance coverage has many nuances, and advocates must be able to make a case for care based on clinical standards.

“Do a careful review on what kind of burden is imposed by insurance companies so you’re able to establish the necessary record when there are improper denials of coverage,” Hufford says.

Parity laws haven’t automatically made access to care easier. In fact, the rules are still being tested in court.

Zuckerman Spaeder filed a federal class action lawsuit May 21 against UnitedHealthcare Insurance Company and United Behavioral Health on behalf of plan members affected by mental health conditions or substance abuse disorders whose coverage was denied. The legal team believes United is not applying parity rules correctly in some situations and wants the insurer to resolve the current complaints and  change its policy for the future.

“The key thing we’re seeking is injunctive relief,” Hufford says “We’re seeking to have United reprocess claims they denied in the past.”

Overly restrictive standards

He says there is very little precedent in mental health parity cases right now. The UnitedHealthcare suit, which was filed in California, calls into question the nonquantifiable restrictions of coverage, such as limits on the number of office visits the insurer would cover for a patient, or coverage for residential treatment for a patient with an eating disorder, for example.

He says United is using overly restrictive care standards as criteria for its coverage—inconsistent with nationally recognized scientific evidence, medical standards, and clinical guidelines—thereby, placing an undue burden on mental-health patients that wouldn’t be applied to patients with other medical conditions.

In some situations, patients were eligible for coverage for a certain level of care, but the insurer required “clear evidence” from the patient or the provider that the specific care was necessary. Without that evidence, care was denied. While insurers are looking to stretch the healthcare dollar as far as it will go, their utilization-management programs in this specific case do not reflect current care standards and place an unequal burden on mental-health patients, he says.

“If you have diabetes, we never see an insurer require clear and compelling evidence that you need care,” he says.

In the case, Zuckerman Spaeder’s argument says UnitedHealthcare is applying the wrong standards to residential care—using the acute inpatient standard rather than looking at the best level of care for the patient’s needs, Hufford says. The same applies to its standard for rehabilitation, in which, it is using withdrawal as the criteria for a patient entering inpatient rehab.

“In withdrawal, you need treatment for the medical condition of withdrawal. And then there is rehab, where you’re not in withdrawal, but need treatment to get sober to prevent sliding back,” he says. UnitedHealthcare, however, made withdrawal part of the criteria to cover rehab treatment. “But someone in rehab should not be in withdrawal,” he says.

Hufford says the suit seeks to uphold legal requirements that mental health conditions and substance abuse disorders are treated consistent with the treatment of other medical conditions. It details violations of the Mental Health Parity and Addiction Equity Act (Federal Parity Act) and the Employee Retirement Income Security Act (ERISA).

 

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My son has a dual diagnosis of ADHD bipolar and substance addiction. United behavior health has made it there mission to fight us on every claim every step of the way. I am ready to fight. if anyone can help. Please email me at becky1574@comcast.net

I am a late stage kidney failure patieny with compounded added damage caused by United Health Care stating they are denying claims and canceling my policy for nob payment when in fact I have bank statements showing on time mobthly payments not including the 1/3 subsidies government pays. Now my dictors, specialists, and lab companies are demanding cash up frobt and turning me into collections all caused by BAD FAITH by UHC specifically designed to beat up on Obamacare plan holders who are high rusk and they want to kick off.
Please help me as now I cant afford my daily anti rejection medication as it is as much as my entire mobthly disability check. I am a former claims manager prior to health insurance games ruining my chances to restore my health. Thank you
markecrisler@yahoo.com

I received a letter on August 14, 2015 where UNH apologized for not recognizing that our premium was already paid. The apology also included their regrets for coverages that may have been declined erroneously. I have thought about going after UNH legally as they have caused many tremendous problems in our family. We have been waiting for someone to bring a class action suit against them.
CB

We were suddenly informed after paying 10 months of premiums, that they are rejecting my husband's anti rejection meds. He is 7 years post transplant and all was okay until we signed on with UHC based on their endorsement by AARP. The company is now shuttling back and forth to Medicare, has denied our doctor expedited recommendation. There have been a total of seven denials for two of three drugs. I also asked for HIPAA info since the refusal said that the claims had been reviewed. They danced a fancy sidestep but finally said that they have no review board. Is there currently a class action that anyone can tell me about because I want to join.

I suffer from severe chronic pain and have been seeing a Pain Management Specialist for the past 8 years. In 2013 I had a Boston Medical spinal cord stimulator surgically implanted which made me a lifetime pain management patient due to the fact that all programing and adjustments have to be made in a clinical environment. Also the fact that I am prescribed opiate pain medication, I have to have my prescription every 30 days. Recently due to change in employment my insurance was charged from 1 United Health care policy to another. Granted, the previous policy had no problem paying my doctor but the new one is now saying that they won't pay until I get a referral from my family physician. I attempted to tell them that both because of my implants and the fact that United Health care has been paying my claims for the past 5 years that I didn't need another referral because I was referred then. The rude woman from I don't know what country proceeded to tell me that referrals are only good for 6 months. I told her that she is wrong because my original referral was 8 years ago and my wife and I have moved 4 times in that period changing insurance every time and this was the first problem ever. I asked for a supervisor only to be given the brush off and then she took my number saying that her supervisor will call me soon. Just another lie because that was over a week ago. Obviously I'm being denied because of a prescription existing condition. Is there an agency to report them to? Are there also any lawsuits that I can join at this time?