United Behavioral Health loses ERISA appeal for mental health coverage

A federal appeals court ruled that coverage for intensive mental health care at United Behavioral Health was repeatedly granted to the parents of a teenage girl.

On May 15 The 10th US Circuit Court of Appeals ruled United Behavioral Health breached its fiduciary duties under the Employee Retirement Income Security Act (ERISA) and acted arbitrarily and in bad faith by denying care and failing to participate in the consultation of the juvenile’s doctors.

A three-judge panel ruled that the U.S. District Court of Utah erred in ordering United Behavioral Health to pay for the teenager’s treatment instead of having United reevaluate its claims.

The decision and order do not use the teenager’s or her parents’ names but identify the teenager with the pronouns she and her.

The case reviewed the due process requirements for medical claims when ERISA applies. In this case, from March 2012 to November 2013, the teenager, named AK, made 10 psychiatric emergency room visits, spent more than 55 days in inpatient care, 55 days in partial hospitalization programs (PHPs), and more than 235 days in residential treatment. Centers for self-injurious behavior.

AK’s parents requested a special case with United Behavioral Health for her to spend a year in a long-term care facility at the recommendation of her doctors and after more than a year of cyclical stays in hospitals, PHPs, and residential settings.

The decision shows that the cyclical nature of her treatment does not allow for the stability needed for recovery, especially when UN Behavioral Health pushes for discharge shortly after 24-hour stabilization into low-care settings where self-injurious behavior reoccurs. .

AK’s parents filed suit after United Behavioral Health’s third-party reviewer, IPRO, initially approved three months of long-term care but denied additional coverage five times.

“We conclude that the district court did not abuse its discretion,” the order states. “Considering [United Behavioral Health’s] Granting clear and repeated procedural errors, injunctions, and additional ‘bites at the apple’ to deny this claim is contrary to ERISA’s fiduciary principles.

The case was first heard in the District Court in December 2017. The District Court decided the case in June 2021, and United Behavioral Health appealed in July 2021.

The case is not unlike any other case that is of great interest to the courts. Wit v. United Behavioral Health addresses the questions of how health plans can handle behavioral health claims under ERISA and parents seeking serious and expensive treatment for their children.

In Witt v. United Behavioral Health, The Main District court case focused on Financial need or not It can affect health plan coverage and if health plans must follow generally accepted medical standards, they must develop internal medicine essential regulations.

In that case, the 9th U.S. Circuit Court of Appeals ruled in part a 2019 district court decision that United Behavioral Health must reimburse nearly 70,000 mental health and addiction treatment claims.

Some see Wit v. United Behavioral Health as ERISA cases Brown v. They described it as the Board of Education.

Although not related to Federal equality lawsquestions about the propriety of rejecting behavioral health claims are part of a broader discussion of behavioral health benefits being argued to be unequal compared to physical health benefits.

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