Anthem Inc. is the target of a proposed class action lawsuit filed in the Eastern District of New York. It accuses the insurance giant of denying residential mental healthcare treatments by using overly strict guidelines.
The lawsuit, which was filed on behalf of Marissa Collins and James Burnett (on behalf of his son), alleges that Anthem’s guidelines violate the Employee Retirement Income Security Act (ERISA). Those guidelines were used until 2018.
The complaint states that under the terms of their plans, a key condition for coverage (medical, surgical, mental health or substance abuse) is that the services for which coverage is sought must be medically necessary. The plan defines medically necessary to mean, among other things “consistent with generally accepted standards of medical practice.”
The lawsuit alleges that Anthem used criteria that was “inconsistent with generally accepted standards of medical practice” and that their guidelines were “flawed” and “inherently unreasonable.” Specifically, the lawsuit alleges that Anthem devised “medical necessity criteria for evaluation of residential mental health treatment that were more restrictive than generally accepted standards. By doing so, it violated the Mental Health Parity and Addiction Equity Act (MHPAEA) incorporated into ERISA.
MHPAEA requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits.
The criteria, the litigation alleges, increased “the relevance of acute behavioral health symptoms while minimizing the relevance of non-acute behavioral health symptoms and conditions.”
Anthem’s criteria meant that those who need more time in a residential treatment facility were denied the coverage needed to fully recover, leaving them to either not receive treatment or to pay for it out of pocket, according to the lawsuit.
Anthem isn’t alone in being sued for this type of behavior. As we wrote about last year, a federal judge ruled that United Behavioral Health breached its fiduciary duty to patients under ERISA by using overly restrictive guidelines to determine whether to pay for tens of thousands of mental health and substance abuse patients’ care. That case grew out of two consolidated class action lawsuits filed in 2014.
The Health Law Offices of Anthony C. Vitale can assist clients with pre-payment, post-payment or issues of non-payment. Give us a call at 305-358-4500 or send an email to firstname.lastname@example.org and let’s discuss how we might be able to assist you.