A class action lawsuit has been filed against Aetna on allegations that the health insurer did not adhere to mental health parity laws for residential treatment services.

The complaint was filed in the U.S. District Court for the Central District of California, where the plaintiff alleged that he had been denied reimbursement for his son, who has been diagnosed with autism spectrum disorder (ASD) and was enrolled in 2019 at a residential care facility in Utah.

The plaintiff had sought reimbursement through the Aetna insurance plan he had with his employer, Fox Entertainment Group. Aetna, which is owned by CVS Health (NYSE: CVS), subsequently denied the plaintiff’s claim.

The lawsuit asserts that Aetna has developed a set of criteria for reimbursing certain residential treatment facilities that is more restrictive than generally accepted professional standards. The standards are designed to “minimize the number of claims accepted … thereby maximizing Aetna’s own profits,” according to portions of the lawsuit that were reported on by Fierce Healthcare.  

The allegations would constitute a violation of the Mental Health Parity and Addiction Equity Act (MHPAEA), otherwise known as the Parity Act, a federal law that went into effect in 2008. Under MHPAEA, health care providers are prohibited from covering behavioral health services more restrictively than medical and surgical services.

The plaintiff also alleged that the reimbursement denial violated the Employee Retirement Income Security Act (ERISA), which sets minimum standards for most private industry pension and health plans. Individuals with private industry plans can bring legal action if they feel that their plan’s insurer unfairly withheld benefits.

“This class action claims that Aetna is not following the law because it is imposing more stringent standards for mental health providers to receive coverage than for some hospitalizations,” Brian Adesman, one of three attorneys who is representing the plaintiff, told Fierce Healthcare. “The standards they are using and the requirements for mental health facilities don’t exist for surgical benefits or physical health benefits. Our client appealed it, and each time Aetna came back and said you don’t meet the requirements and refused to cover the cost.”

In a letter to the plaintiff, Aetna said his claim was denied because his son’s residential facility was not accredited by such bodies as The Joint Commission, the Committee on Accreditation of Rehabilitation Facilities, the American Osteopathic Association’s Healthcare Facilities Accreditation Program or the Council on Accreditation. Aetna also contended in the letter that the reimbursement denial was due to other factors such as the facility not providing the plaintiff’s son treatment at least once a week, but on an as-needed basis.

Through an Aetna spokesman, the company told Fierce Healthcare it would not comment on the pending litigation, but said it “takes mental wellbeing very seriously,” while noting that it has long been a champion of the Parity Act.

“Aetna was an early advocate of the passage of the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008, as well as legislative efforts that predate MHPAEA,” the spokesman said in a statement to Fierce Healthcare. “We view the law as a landmark achievement for mental health. We will continue to be a strong advocate of the law and for comprehensive access to mental health resources that are covered by our health plans.”

Attorneys for the plaintiff told Fierce Healthcare that their client is currently the sole party on the lawsuit, but that the complaint could be amended to add other Aetna members who may have been denied mental health benefits.