Judge Finds UnitedHealthcare Coverage Guidelines Over-Emphasized Acute Problems, 'Cost-Cutting'
A federal judge in San Francisco has found that an affiliate of the nation's largest health insurer breached its fiduciary duty to policyholders by following coverage guidelines for mental health problem and substance abuse issues that resulted "in a significantly narrower scope of coverage than is consistent with generally accepted standards of care."
March 05, 2019 at 06:02 PM
4 minute read
A federal judge in San Francisco has found that an affiliate of UnitedHealthcare, the nation's largest health insurer, breached its fiduciary duty to policyholders by following guidelines that emphasized cost-savings and addressing acute problems rather than treating underlying mental health and substance abuse issues.
U.S. Magistrate Judge Joseph Spero of the Northern District of California issued a 106-page ruling Tuesday finding that the guidelines that United Behavioral Health used when making coverage decisions in cases of mental illness and substance abuse didn't provide for generally accepted standards of care outlined in the plaintiffs' policies.
“In every version of the Guidelines in the class period, and at every level of care that is at issue in this case, there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members' underlying conditions,” Spero wrote. Although the specific guidelines used to make a coverage decision varied within the class period from 2012 to 2017, Spero concluded that emphasis was “pervasive and result[ed] in a significantly narrower scope of coverage than is consistent with generally accepted standards of care.”
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