A North Carolina judge ruled against Aetna Feb. 9 over an "all or nothing" policy that allegedly resulted in mismatched reimbursements and denied claims for a mental health recovery, according to court documents.
The lawsuit was filed in August 2020 by a North Carolina parent on behalf of their child, who in 2018 received care at an inpatient recovery program for individuals with mental health or substance abuse disorders. Later, the plaintiff graduated from the program and moved to a transitional program with the same provider.
Aetna initially denied coverage of both programs, claiming they were medically unnecessary. The father contested the decision, and a third party review found only the first program was necessary.
While Aetna partially covered care for the first program, the father argued in the lawsuit that Aetna should have covered all of the program. He also claimed that Aetna issued varying payments month to month for seemingly the same services.
The court sided with Aetna, claiming that the family's health plan provisions justified partial payment, but the payer did "not make reasoned and principled decisions" in its varied payments month to month and "abused its discretion."
Additionally, the court found that because Aetna covered the first, more intensive program, under medical necessity, it should have covered the transitional treatment as well, which was a step down. The ruling claimed Aetna's "all or nothing approach was not a reasoned and principled decision making process and not a full and fair review."
The loss means Aetna must compensate plaintiffs for both programs, as well as attorney's fees.