Psych-Appeal Files Class Action Against Aetna for Denying Depression Treatment

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Psych-Appeal, in conjunction with Zuckerman Spaeder LLP and LeClairRyan, P.C., has filed a class-action lawsuit against Aetna on behalf of mental health patients suffering from depression. The federal lawsuit alleges that Aetna has categorically refused to cover a safe and effective treatment called Transcranial Magnetic Stimulation (TMS).

“Aetna has unjustifiably categorized TMS as ‘experimental and investigational’ while Medicare and numerous commercial insurers routinely cover it,” said Brian Hufford, partner at Zuckerman Spaeder LLP. “By denying coverage for TMS, Aetna is preventing patients from receiving potentially lifesaving care.”

In 2008, the U.S. Food and Drug Administration cleared TMS for patients who have failed to respond to psychotropic medications. Unlike electroshock therapy, TMS is performed on an outpatient basis without sedation and does not typically result in side effects such as memory loss.

The complaint also alleges that MCMC, LLC, an independent review organization directly contracted with Aetna to evaluate external appeals of the company’s TMS denials, rubber-stamps the insurer by relying on outdated clinical research and misapplying health plan criteria that violate the federal Mental Health Parity and Addiction Equity Act.
“This case will be among the first to highlight the conflicts of interest that independent review organizations have when they are allowed to contract directly with insurers to evaluate claim denials,” said Meiram Bendat, mental health attorney and founder of Psych-Appeal.

The class action has been filed with co-counsel Elizabeth K. Acee and Daniel P. Elliott of Connecticut-based LeClairRyan, P.C.

Related coverage:

Conn. Insurer Sued for Not Covering ‘Magnetic’ Depression Treatment, The Connecticut Law Tribune, September 21, 2015

“A Long Road Ahead” – NAMI Study Looks at Mental Health Parity

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A recent study by the National Alliance on Mental Illness (NAMI) has found significant and troubling barriers that people with mental illness and substance use disorders encounter in obtaining quality  care. While the Affordable Care Act extends parity requirements to essential mental health and substance abuse benefits, NAMI reports in “A Long Road Ahead – Achieving True Parity in Mental Health and Substance Use Care” that more needs to be done in ending discriminatory coverage of these illnesses in health insurance plans.

Among the report findings are the following: consumers and family members have serious problems finding mental health providers in their health plans; insurers deny authorization of mental health care at higher levels than that of other medical care; significant barriers exist when accessing psychiatric medications in health plans; and high out-of-pocket costs for prescription drugs and/or inpatient and outpatient care can deter people from getting the treatment they need.

“Although people living with mental illness and substance use disorders are grateful for the steps Congress and the Administration have taken to increase fairness through MHPAEA and the ACA, the problems described in this report must be addressed for the great promise of these landmark laws to translate into improved access to quality care,” concludes the study’s authors.

Psych-Appeal’s Meiram Bendat Featured on NPR’s ‘On Point’

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“Why don’t we have mental health parity?”

That’s the discussion on NPR’s “On Point” today, featuring Psych-Appeal founder Meiram Bendat.  Guest host Jane Clayson notes that insurance companies must pay for mental health benefits the same as they do for medical care. But do they? Calling it “the problem of parity in health insurance,” the one-hour show delves into deductibles, the Affordable Care Act, and lack of enforcement of the Parity Act.

Listen here.

Federal Appeals Court Rules Patients Can Sue Insurers for Violation of Parity Act

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In a precedent-setting decision, the United States Court of Appeals for the Second Circuit ruled today that claims administrators who exercise “total control” over health plans may be sued for breaching their fiduciary duties under the Employee Retirement Income Security Act of 1974 (“ERISA”). The appeals court ruled that a state psychiatric association may also sue in a representational capacity on behalf of its psychiatrist members and their patients to seek broad-based injunctive for violations of mental health parity mandates. The ruling sends New York State Psychiatric Association, Inc. et al. v. UnitedHealthGroup et al. back to the U.S. District Court for the Southern District of New York.

“The ruling is exceptional for a variety of reasons,” explained Meiram Bendat of Psych-Appeal, co-counsel for the plaintiffs. “The Second Circuit clearly understood that patients should not have to sue their employers, who are typically the benefit sponsors, to enforce parity compliance by claims administrators who act as health plan fiduciaries.”

Further details are provided in the ruling and the press release.

Related coverage:

Second Circuit Reinstates Mental Health Parity Case Against UnitedHealth, National Law Review, September 15, 2015

Mental Health Parity Ruling Called ‘Watershed’ Case, Bloomberg, August 25, 2015

CBS Sports worker can sue UnitedHealth over mental health parity, Business Insurance, August 21, 2015

Appeals Court Decision Could Push Enforcement of MH Parity Law, Psychiatric News, August 20, 2015

Statement of Patrick J. Kennedy on New York Psychiatric Association v. UnitedHealth Group Ruling, The Kennedy Forum, August 20, 2015

Insurer Dogged by Claim of Mental Health Bias, Courthouse News Service, August 20, 2015

NPR’s ‘All Things Considered’ Airs Segment on Mental Health Parity

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On July 29, 2015, NPR’s “All Things Considered” aired an important story regarding the lack of public enforcement by state and federal governments of the federal mental health parity law. The segment discusses a class-action suit by Psych-Appeal against UnitedHealthcare and can be accessed here.

EmblemHealth Sued for Alleged Violations of New York Mental Health Parity Law

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Psych-Appeal and Zuckerman Spaeder LLP filed a new mental health parity lawsuit in New York today against EmblemHealth, Inc., which insures the employees of the City of New York and which has contracted with ValueOptions to administer its behavioral health benefits. The complaint alleges that EmblemHealth, acting through ValueOptions, fails to provide coverage for “serious emotional disturbances” of children, as required by the New York mental health parity law, also known as Timothy’s Law.

While EmblemHealth and ValueOptions publish prevailing clinical guidelines for the treatment of biologically based mental illnesses, such as major depression, on their websites, they do not publish prevailing clinical guidelines for the treatment of Oppositional Defiant Disorder and Conduct Disorder. These disruptive disorders often require intensive psychosocial rehabilitation to address their hallmark symptoms, namely oppositionality and defiance.

The suit challenges EmblemHealth’s coercive insistence on psychotropic medications, even when such medications are not a first-line treatment for serious emotional disturbances of adolescents who must generally establish strong therapeutic alliances prior to medication trials.  The suit also alleges that EmblemHealth abdicates its role to provide inpatient coverage by directing adolescents with serious emotional disturbances for long-term treatment in state hospitals.

EmblemHealth and ValueOptions both entered into Assurances of Discontinuance with the New York Attorney General in 2014 and 2015 for violating the New York and federal mental health parity laws.

Federal Court Rules That Exclusion of Residential Treatment May Violate Federal Parity Act

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The United States District Court for the Northern District of Illinois has ruled that an insurer’s blanket exclusion of residential treatment is “arguably at odds with [the Federal Parity Act’s] purpose to achieve coverage parity whenever a plan offers both mental-health and medical/surgical benefits.”

The federal court held that “[t]he practical effect of the [residential treatment] exclusion is that Jane Doe receives fewer hours (or days) of coverage for medically necessary nursing care than, for example, an elderly person would receive to rehabilitate a broken hip.”

In the fall of 2014, Psych-Appeal, along with the law firms of Barnhill & Galand P.C. and Zuckerman Spaeder LLP, filed a class-action suit, Craft et al v. Health Care Service Corporation, on behalf of an adolescent struggling with anorexia, depression, and post-traumatic stress disorder whose claims for residential treatment were categorically denied following nine psychiatric hospitalizations. Residential treatment is often the most appropriate, if not the only suitable level of care for individuals with chronic mental health or substance use disorders, which are frequently under-diagnosed and under-treated.

“When patients do not have access to all levels of mental health services across the continuum of care, their welfare can be imperiled,” said Meiram Bendat of Psych-Appeal.

Additional information is provided in the press release.

Patrick Kennedy Responds to ’60 Minutes’ Story Revealing Mental Health Coverage Denials

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Mental health advocate and former Congressman Patrick Kennedy appeared on “CBS This Morning” today to discuss how insurer denials of mental health treatment adversely affect the lives of those dealing with mental illness.

“It’s an all too familiar tragedy that mental health is not treated like the rest of physical health,” said Kennedy. “The notion that there was 95 percent to 100 percent denial rate for mental illness, where as you would never expect that for cancer, diabetes or cardiovascular disease.”

Kennedy called upon insurance companies to outline how they decide whether a claim for mental health treatment is medically necessary.

“What’s most frustrating is the lack of transparency in how [insurance companies] make these decisions,” he said.

The “60 Minutes” investigation aired last night on CBS.

’60 Minutes’ Features Psych-Appeal Client

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The investigative news program “60 Minutes” has examined the alarming frequency with which health insurance companies refuse mental health treatment claims—and the story features one of Psych-Appeal’s clients. The segment aired the evening before the U.S. Court of Appeals for the Second Circuit will consider whether employees with mental illness can directly sue health insurers who deny their claims rather than the employers who sponsor their benefits.

An insightful and powerful report, we commend those featured in this story for their courage in speaking publicly about the denials they experienced.

Lawsuit Filed Against UBH Alleges Restrictions of Mental Health Insurance Coverage

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Psych-Appeal Inc. and Zuckerman Spaeder LLP have filed a class-action lawsuit against United Behavioral Health (UBH) on behalf of several individuals who suffer from mental health and substance abuse conditions. The suit alleges that UBH improperly limits and denies insurance coverage for outpatient mental health and substance abuse treatment through restrictive internal guidelines. It challenges UBH’s “medical necessity” criteria and argues that claim denials violate UBH’s obligations under ERISA.

“United Behavioral Health’s level of care guidelines are far more restrictive than the standards of care that are generally accepted within the mental health community,” said Meiram Bendat, founder of Psych-Appeal. “By conditioning coverage on a patient’s ability to prove that she is in the midst of a crisis, UBH ignores the chronic nature of most mental illnesses and harms patients.”