UnitedHealth members say mental health coverage is 'controlled' by finance department in new appeal

UnitedHealth Group members have asked a federal appeals court to reassess a former ruling in favor of a UnitedHealth subsidiary they say has led to "disastrous consequences" for employee benefit plans and millions of mental health and addiction patients.

The appeal was filed March 10 in the 9th U.S. Circuit Court of Appeals and is part of a legal battle over mental health coverage that stretches back to 2014.

In the original class-action complaint, United Behavioral Health was accused of wrongfully denying members' behavioral health claims based on internal standards "controlled" by the finance department, rather than those established by the medical community.

Because of the allegation that UBH acted in its own self-interest, the plaintiffs claim the subsidiary violated its duties under the Employee Retirement Income Security Act, a federal statute that oversees employer-sponsored health coverage.

"In short, this is one of the most important ERISA cases — perhaps the most important ERISA case — of the 21st century," the plaintiffs' attorneys wrote.

In 2019, the U.S. District Court for Northern California ruled that UBH's behavioral coverage denials violated state laws and were "infected" by financial incentives — in 2020, the same court ordered the company to reprocess 67,000 mental health and substance abuse claims.

In March 2022, the 9th Circuit Court of Appeals reversed the district court's decisions. 

Several states, the American Hospital Association, American Psychological Association and others sided with the plaintiffs and appealed the decision in May 2022.

In January 2023, the 9th Circuit issued a new ruling that partly ruled in favor of the plaintiffs by saying that some members saw a breach of fiduciary duty from UBH, but it did not order claims to be reprocessed nor halt UBH from using its internal guidelines, according to Law360.

In the appeal filed March 10, the plaintiffs are asking the court to rule that UBH must follow the medical community's "generally accepted standards of care."

"Virtually every insurer in America uses commercial guidelines in its medical-necessity reviews," the plaintiffs wrote. "… allowing insurers to use these guidelines to deviate from the medical community's standards will have an enormous and devastating impact."

Becker's has reached out to UnitedHealthcare for comment and will update this article if more details become available.

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