Court Rules UBH Coverage Guidelines A Monumental Fixer-Upper

Earlier this month, on March 5, 2019, the U.S. District Court in the Northern District of California filed a 106-page Findings of Fact and Conclusions of Law in the class action Wit v. United Behavioral Health ("UBH").

Here are the highlights:

• Under ERISA, Plaintiffs asserted two claims against UBH based on UBH's Level of Care Guidelines and Coverage Determination Guidelines (collectively, "Guidelines"): (1) breach of fiduciary duty, and (2) arbitrary and capricious denial of benefits.
• The court agreed, and ruled that:
  
  
  • The Guidelines did not follow generally accepted standards of care; and
  • The Guidelines were tainted by the UBH Financial Department's significant involvement in their development and implementation.
• The Guidelines prioritized addressing acute symptoms while ignoring the effective treatment of members' underlying conditions.
• The record was "replete with evidence" that UBH Guidelines were used to mitigate the impact of the 2008 Parity Act. For more on the Parity Act, see our blog post " Mental Health Parity Really Does Mean Equal Benefits".
• UBH based its decisions with respect to coverage of important treatments, such as Transcranial Magnetic Stimulation ("TMS"), a treatment for major depressive disorder, and Applied Behavioral Analysis ("ABA"), a treatment for autism spectrum disorder, in part, on how coverage would negatively affect UBH's finances.

Conclusion:

Wit brings to light—with a staggering amount of evidence and clarity—the dangers of putting financial interests ahead of members' health coverage needs. Wit is likely just the beginning. Click here to see a detailed summary of the case.

To read the full opinion for Wit v. United Behavioral Health, please click here.

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