Blue Cross Blue Shield of Florida Sued for Allegedly Using Tactics Similar to Wit Case
Psych-Appeal and Zuckerman Spaeder LLP have filed a class-action complaint alleging that Blue Cross Blue Shield of Florida (BCBSF) and its behavioral health claims administrator, New Directions Behavioral Health, used improper internal guidelines to illegally deny health insurance coverage to a 20-year-old woman suffering from a severe eating disorder.
The lawsuit is part of the two law firms’ national efforts on behalf of patients and health providers to ensure insurers comply with federal and state parity laws. Today’s filing follows a federal court’s monumental ruling in March regarding Wit et al v. United Behavioral Health, in which the judge said UBH denied mental health coverage claims based on internal guidelines that were “unreasonable and an abuse of discretion.” Psych-Appeal’s Meiram Bendat was the attorney who uncovered the guideline flaws in that historic case.
In this complaint filing, the plaintiff, who suffers from generalized anxiety disorder and anorexia nervosa, alleges that New Directions applied faulty “medical necessity” criteria to repeatedly deny coverage at a residential facility, despite the fact that the treatment was covered by her BCBSF plan and is consistent with generally accepted standards of care.
“Once again, we see an insurer putting profits before patients by callously applying flawed internal guidelines to repeatedly deny treatment that is desperately needed – and indeed, promised by this woman’s health plan,” said Bendat, co-counsel for the plaintiff. “The basis of these denials – on the one hand, saying it’s not medically necessary and on the other, saying the plaintiff is too sick to be successfully treated at a residential facility – expose the ludicrous nature of allowing insurers to set their own guidelines for approving mental health coverage. Such tactics are routine among health insurers across the industry and it must be stopped.”
In using improper internal guidelines, the lawsuit argues that the companies breached their fiduciary duties to plan members and beneficiaries, which, in turn, violated the Employee Retirement Income Security Act (ERISA), the basis upon which the defendants are being sued.
The complaint – Susan Hering v. New Directions Behavioral Health, L.L.C., and Blue Cross Blue Shield of Florida, Inc. – was filed in the U.S. District Court for the Middle District of Florida.
Regarded as a nationally recognized leader in mental health parity litigation, Psych-Appeal has spearheaded some of the highest-profile cases in the U.S., including the landmark Wit et al. v. United Behavioral Health. The firm represents patients and health care providers in overcoming denials of mental health coverage by health insurance companies. Its groundbreaking application of ERISA and other related federal and state parity laws has resulted in precedent-setting wins. The firm collaborates with mental health thought leaders, including The Kennedy Forum and The Saks Institute for Mental Health Law, Policy, and Ethics.
Related coverage:
Insurer, Behavioral Health Co. Sued Over Live-In Treatment, Law360, September 5, 2019 (NOTE: This link is available to Law360 subscribers. Access a PDF version of the article here.)