Class-action lawsuit alleges that Aetna violated parity requirements for mental health services
The complaint alleges that Aetna imposes a set of overly restrictive criteria to determine which residential treatment facilities are covered.
The demand for behavioral health services is soaring during the pandemic, and consumers are beginning to challenge decisions by insurance providers. A class-action lawsuit filed this week in U.S. District Court in the Central District of California alleges that Aetna illegally denied claims for mental health residential treatment services.
In 2019, the plaintiff, who has an Aetna insurance plan through his employer, enrolled his 16-year-old son with autism spectrum disorder in a mental health residential treatment center in Utah. Aetna denied the plaintiff’s claim for reimbursement for his son’s treatment at the residential facility.
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The complaint alleges that Aetna imposes a set of internally developed criteria to determine which residential treatment facilities receive coverage that are far more restrictive than generally accepted professional standards to “minimize the number of claims accepted and thereby maximizing Aetna’s own profits,” according to the lawsuit.
The plaintiff alleges that having more stringent standards for mental health treatment coverage violates the Mental Health Parity and Addiction Equity Act of 2008, also called the Parity Act, and the Employee Retirement Income Security Act. The Parity Act aims to block insurers from hindering access to behavioral health. Although the Parity Act does not require health care plans to cover mental health services, if a plan chooses to do so, such coverage must be provided at parity with medical and surgical benefits.
“Unfortunately, in administering the Aetna plans, Aetna treats mental health as less important than physical health,” the plaintiff said in the complaint.
Aetna said in a letter that it was denying coverage because the facility is not accredited by an agency such as The Joint Commission, the Committee on Accreditation of Rehabilitation Facilities, the American Osteopathic Association’s Healthcare Facilities Accreditation Program or the Council on Accreditation.
“This class action claims that Aetna is not following the law because it is imposing more stringent standards for mental health providers to receive coverage than for some hospitalizations,” attorney Brian Adesman, who is representing the plaintiff, told Fierce Healthcare. “The standards they are using and the requirements for mental health facilities don’t exist for surgical benefits or physical health benefits. Our client appealed it, and each time Aetna came back and said `you don’t meet the requirements’ and refused to cover the cost.”
In a statement provided to Fierce Healthcare, an Aetna spokesman said, “While we’re not commenting on this pending litigation at this time, we take mental well-being very seriously. It is an enterprise priority that drives partnerships with organizations, providers and employers to improve mental health care nationwide.
“Aetna was an early advocate of the passage of the Mental Health Parity and Addiction Equity Act in 2008, as well as legislative efforts that predate MHPAEA. We view the law as a landmark achievement for mental health. We will continue to be a strong advocate of the law and for comprehensive access to mental health resources that are covered by our health plans.”
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