Aetna hit with ERISA lawsuit after repeatedly denying mental health coverage

Aetna is one of the latest health care insurance companies to be hit with an Employee Retirement Income Security Act lawsuit after repeatedly denying a father’s claims for coverage for his daughter’s inpatient mental health treatment.

Aetna and Susquehanna International Group Benefits Plan were named in the Feb. 10 suit, filed in the U.S. District Court for the District of Utah by the Salt Lake City-based law office of attorney Brian S. King on behalf of a plaintiff, David D., and his minor child, S.D.

The complaint brings claims for recovery of benefits under violation of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which compels “insurers to ensure that coverage for mental health benefits was offered in accordance with coverage for analogous medical or surgical care.”

After years of back-and-forth between David D. and Aetna, he claims Aetna failed numerous times to consider the relevant period of treatment and S.D.’s treatment changed. Despite his numerous appeals, Aetna and independent reviewers denied his claims.

According to David D., he submitted letters from numerous health professionals, including doctors and therapists, who allegedly attested to S.D.’s ongoing mental health struggles, and shared the belief that she would benefit from residential care. However, payment was still denied, resulting in David D. allegedly incurring more than $550,000 in medical expenses.

King, the plaintiffs’ attorney, did not immediately respond to a request for comment.

Counsel have not yet appeared for the defendants.

The suit is part of a wave of cases challenging health insurers’ denial of coverage for inpatient mental health and substance abuse treatment, including suits against UnitedHealth and Cigna. Both suits, also filed by King’s firm, revolve around the denial of coverage for mentally ill teenagers and young adults who have sought inpatient treatment, often after different types of therapy and treatment.

Over the past few months King’s firm has filed numerous suits against insurance companies on behalf of minors in various district courts, many of which have been filed in Utah. The suits argue that the insurance companies failed to comply with their obligations under ERISA, including failing to conduct proper review of the claims and provide necessary information.

In one suit, Cigna allegedly denied coverage as the treatment facility the father’s daughter was admitted to wasn’t covered by the plan.

Another child’s treatment was also allegedly denied by United Healthcare, as the treatment center’s service components were allegedly inconsistent with United Healthcare’s “Child and Adolescent Service Intensity Instrument (CASII) Guidelines,” and therefore United Healthcare claimed it could not authorize the facility.

United Healthcare is also accused of denying a mother’s attempts to cover her daughter’s inpatient treatment, finding no further authorization could be provided as the child made progress and her condition didn’t meet the guidelines for further coverage in that treatment setting. This conclusion was allegedly reached as she had “been following the roles on the unit,” with United Healthcare allegedly determining she was no longer depressed and didn’t have “active suicide plans,” and therefore didn’t need “24 hour nonacute medical care,” according to the complaint.

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In the suit against Aetna, the plaintiffs allege that the company’s reason for denying coverage was because since the minor ”did not need direct supervision to eat, take medicine, or follow directions, and didn’t require a 24-hour treatment program, treatment at the residential level was not medically necessary.”