A federal appeals court has revived a lawsuit alleging UnitedHealthcare applies more stringent standards to approving behavioral healthcare than comparable medical or surgical care.
In a ruling issued April 11, the 9th Circuit Court of Appeals ruled the case should be further reviewed, reversing a lower court's decision. The case was first filed in 2019 by a plaintiff identified as Ryan S., who alleged UnitedHealth applied more stringent criteria to review out-of-network claims for mental health and substance use treatment than medical care.
The plaintiff alleged UnitedHealth subsidiary United Behavioral Health violated its duties under the Employee Retirement Income Security Act, a federal statute that oversees employer-sponsored health coverage, and the Mental Health Parity and Addiction Equity Act of 2008.
The court reversed the lower court's ruling that the plaintiff had not adequately identified different standards for mental and physical healthcare. The court concurred with the lower court that the plaintiff had not identified any instances where medical claims he submitted were processed differently than claims for mental healthcare. The plaintiff also cited a 2018 report from California's Department of Managed Health Care that found UnitedHealthcare violated some of the state's mental health parity laws.
According to the court's opinion, Ryan S. completed two out-of-network substance use disorder programs between 2017 and 2019. UnitedHealthcare's plan was supposed to cover 70% of the charges before the out-of-pocket maximum is met, and 100% after. The plaintiff alleged he was left to pay most of the cost of the program himself.
In its opinion, the court wrote that the mental health parity act lacks clear guidance on its applicability to ERISA-covered plans, often leading to improvised standards among district courts.
UnitedHealthcare is also facing a class-action lawsuit alleging it wrongfully denied members' behavioral health claims. The 9th Circuit issued a ruling partly in favor of the plaintiffs, saying that United Behavioral Health breached its fiduciary duty in handling some member's claims. The court did not order the insurer to reprocess claims or order it to change its internal guidelines.
The plaintiffs in the case filed an appeal in March, asking the court to rule that United Behavioral Health must follow "generally accepted standards of care."
Becker's has reached out to UnitedHealthcare for comment and will update this article if more details become available.