A federal appeals court has ruled in favor of the parents of a teen girl frequently denied coverage for intensive mental health care by United Behavioral Health.
On May 15, the 10th U.S. Circuit Court of Appeal ruled that United Behavioral Health violated its fiduciary duties under the Employee Retirement Income Security Act (ERISA) and acted arbitrarily and capriciously in its denials of care and by not engaging with the advice of the teen’s doctors.
The three-judge panel also found that the U.S. District Court for the District of Utah, where the case originated, did not err in ordering United Behavioral Health to pay for the teen’s treatment, rather than having United review the claims again.
The decision and order do not use the teen or her teen parents’ names but identify the teen with the pronouns her and she.
The case assessed the procedural requirements for medical claims where ERISA applies. In this case, from March 2012 to November 2013, the teen identified in the order as A.K. had 10 psychiatric emergency room visits, spent over 55 days in inpatient care, 55 days in partial hospitalization programs (PHPs) and over 235 days in residential treatment centers related to care for self-injurious behavior.
A.K.’s parents sought a case exception with United Behavioral Health for her to spend a year in a long-term treatment facility at the recommendation of her doctors and after more than a year of cyclical stays in hospitals, PHPs and residential settings.
The decision states that the cyclical nature of her treatment didn’t allow for the needed stability for recovery, especially as United Behavioral Health repeatedly pushed for discharge soon after 24-hour stabilization to lower levels of care where the self-injurious behavior would again occur.
A.K.’s parents sued after United Behavioral Health’s third-party reviewer IPRO initially approved a three-month stay in long-term care but denied further coverage five times.
“We conclude that the district court did not abuse its discretion in declining to remand,” the order reads. “Considering [United Behavioral Health’s] clear and repeated procedural errors in denying this claim, it would be contrary to ERISA fiduciary principles to mandate a remand and provide an additional ‘bite at the apple.'”
The case was originally filed 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 has loose similarities to another high-interest case in the courts. Wit v. United Behavioral Health deals with questions about how health plans can handle behavioral health claims according to ERISA and involve parents seeking intensive and expensive treatment for their children.
In Wit v. United Behavioral Health, the original district court case centered on whether or not financial interests may impact health plan coverage and if health plans must follow generally accepted medical standards in developing internal medical necessity rules.
In that case, the 9th U.S. Circuit Court of Appeals undid a 2019 district court ruling that, in part, ruled that United Behavioral Health needed to reprocess nearly 70,000 mental health and addiction treatment claims.
Some have described Wit v. United Behavioral Health as the Brown v. Board of Education of ERISA cases.
While not related to the federal parity laws, questions over the appropriateness of denying behavioral health claims are part of the wider discussion of the allegedly unequal treatment of behavioral health benefits compared to physical health benefits.
Companies featured in this article:
10th U.S. Circuit Court of Appeal, 9th U.S. Circuit Court of Appeals, United Behavioral Health
