- A federal judge sided with the plaintiffs who sued UnitedHealth Group's United Behavioral Health after they were denied coverage when seeking care for substance use disorder treatment and other behavioral health treatment.
- United Behavioral Health created and used its own guidelines in coverage determinations. However, a judge found that the guidelines were more restrictive than generally accepted standards of care. Judge Joseph Spero wrote in a filing Tuesday that "clinical judgment is constrained by the criteria for coverage set forth in the Guidelines, which are mandatory."
- Development of the guidelines was based "as much or more on its own bottom line" than the interest of its members, Spero concluded. The only reason UBH declined to adopt American Society of Addiction Medicine criteria as its guidelines was because the finance department did not sign off on the change, giving the division veto power over its clinicians who all backed the use of ASAM criteria, Spero said.
The ruling against by some measures the biggest private health insurer is likely to influence how coverage decisions are made for mental health and substance use disorder services for tens of millions of patients.
At issue in this case is UBH's own guidelines, but also how — as the claims administrator for some plans — it was interpreting a health plan's terms and whether to cover a claim. Sometimes UBH's coverage decisions were at odds with the member's own health plan terms, the court found.
"Such unfettered discretion to modify the terms of the Plans without notice to Plan participants and beneficiaries flies in the face of ERISA," Spero wrote.
"We look forward to demonstrating in the next phase of this case how our members received appropriate care," UnitedHealth said in a statement sent to news outlets. "We remain committed to providing our members with access to the right care for the treatment of mental health conditions and substance use disorders."
The ruling comes as advocates are seeking equal treatment for mental services under health plan coverage decisions.
There has been a push from the federal government in recent years to ensure that mental health services are covered just like other physical and medical conditions. The Mental Health Parity and Addiction Equity Act forbids insurers from providing limitations on mental health treatment than they would for medical or surgical treatment.
But over the years, some have questioned whether there is enough rigorous enforcement.