United HealthCare Mental Health Coverage Parity Class Action

The complaint for this class action claims that United HealthCare Insurance Co. (UHIC) and United Behavioral Health (UBH) impose reimbursement penalties on claims for coverage for psychotherapy services, which the complaint says is a violation of the Employee Retirement Income Security Act (ERISA) parity provisions and the Affordable Care Act (ACA).

The class for this action is all participants in or beneficiaries of ERISA plans whose claims for out-of-network behavioral health services were subjected to United’s Discriminatory Reimbursement Penalty, excluding plans issued by Oxford Health Insurance, Inc. 

Plaintiff Jane Smith suffers from post-traumatic stress disorder. To treat this problem, she receives psychotherapy from a licensed clinical social worker with a master’s degree and an additional twenty-eight years of experience. Smith became insured by United in 2018. The social worker is out of network (ONET), meaning that she has no agreement with United to accept their network levels of payment. 

When Smith began submitting her claims for these sessions to United, the complaint says, United determined that the sessions were covered under the plan and issued benefit payments for them. The complaint therefore says that whether or not the sessions were covered is not in dispute. What is in dispute, it seems is the amount of benefits United wants to pay for the sessions.

Under Smith’s Plan, the complaint says, ONET benefits are determined based on an “Eligible Expense,” the maximum amount of the provider’s bill that United is willing to reimburse. As quoted in the complaint, however, the plan says that for mental health services, “the Eligible Expense will be reduced by 25% for Covered Health Services provided by a psychologist and by 35% for Covered Health Services provided by a masters level counselor.” This means that United reduced the Allowed Amount on Smith’s claims by 35%.

Smith’s counselor bills her sessions at $120; United reimbursed the sessions at $61.86. Additional half-hours were billed at $60; United reimbursed for them at $29.55. 

According to the complaint, this is a violation of the Parity Act (officially, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008). The Parity Act says that insurers must cover mental health services on the same terms as they cover medical and surgical services.

Smith appealed the payment amount, but United denied her appeal. It also denied her second-level appeal. 

The complaint claims violations of ERISA and the ACA, including violations of the Parity Act and breach of fiduciary duty. 

Article Type: Lawsuit
Topic: Consumer
Tags: Denial of Benefits, ERISA Violations, Mental Health Parity Issue