Huge Case: Judge Targets Mega Health Insurer for Illegally Denying Care to Thousands

Huge Case: Judge Targets Mega Health Insurer for Illegally Denying Care to Thousands
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A subsidiary of the nation’s largest health insurer has heavily angered a federal judge, who says that the company focused on the “bottom line as much or more” than patients’ health – illegally.

US Chief Magistrate Judge Joseph Spero said United Behavioral Health, a subsidiary of UnitedHealthcare, illegally denied treatment to thousands of people and slammed the company’s medical directors for being “deceptive” under oath.

According to Spero, United Behavioral Health created internal policies that were discriminatory against those seeking mental health and substance abuse treatment.

He said:

“It is well-established that effective treatment of mental health and substance use disorders includes treatment aimed at preventing relapse or deterioration of the patient’s condition and maintaining the patient’s level of functioning. UBH Guidelines deviate from that standard.”

Legal observers are calling the ruling one of the most important and most thorough-ever issued against an insurance company at the federal level on mental health issues.

Patrick Kennedy, the former US representative from Rhode Island, said the ruling is akin to landmark 1954 Supreme Court decision that found racial segregation in public schools unconstitutional.

“This ruling is the Brown v. Board of Education for the mental health movement. The insurance industry is hellbent on violating the federal law, and they’re doing so with impunity. Now, we have a federal court specifically and forensically breaking down how they get around the federal law.”

The class-action suit was brought on behalf of more than 50,000 people denied coverage by United Behavioral Health, the largest managed behavioral healthcare organization in America.

In his 106-page decision, Spero ruled that UBH violated state laws in Illinois, Connecticut, Rhode Island, and Texas. The judge called out the insurer’s medical directors and expert witnesses by name, discounting their testimony and deeming them not credible.

“UBH’s experts, on the other hand, had serious credibility problems. The Court found that with respect to a significant portion of their testimony each of them was evasive – in their answers when confronted with contrary evidence.”

In one example cited by Spero, a board-certified psychiatrist and senior medical director, who was tasked with supervising and training United Behavioral Health care advocacy clinicians, “was not always credible because in several instances he ignored the plain meaning of the words used in the Guidelines.”

Another company expert, whose job it was to draft coverage determination guidelines, implemented “a model that keeps benefits expenses down by placing a heavy emphasis on crisis stabilization and an insufficient emphasis on the effective treatment of co-occurring and chronic conditions.”

In other words, UBH emphasized covering mental health crises while failing to emphasize maintenance treatment. It would be like if an insurer covered the care of someone in a diabetic coma but they refused to cover their daily insulin regimen and follow-up treatment.

Spero said:

“Research has demonstrated that patients with mental health and substance use disorder who receive treatment at a lower level of care than is clinically appropriate face worse outcomes than who are treated at the appropriate level of care.”

Patients said they were denied care as soon as they appeared stable. One of the plaintiffs in the case claims her son, who struggled with substance abuse, was treated at a residential treatment facility and subsequently died after the facility kicked him out when UBH denied him coverage. [2]

In an e-mail, UnitedHealth maintained that it had not failed to provide the proper care.

“We look forward to demonstrating in the next phase of this case how our members received appropriate care. We remain committed to providing our members with access to the right care for the treatment of mental health conditions and substance use disorders.”

A final judgment is expected to be handed down by Spero in the next few months.


[1] CNN

[2] The New York Times