Health Insurance Providers Allegedly Committed Insurance Fraud and Violated ERISA For Purported Improper Mental Health Care

On Nov. 25, 2020, a case was filed against UNITED HEALTHCARE INSURANCE COMPANY (‘UHC’), CIGNA HEALTH and LIFE INSURANCE COMPANY (‘CIGNA’), and the UTC CHOICE MEDICAL PLAN (‘UTC’) regarding their denial of coverage for mental health treatment for a minor child. The case, filed in the District of Utah, Central Division, alleges improper standards applied to medical necessity evaluations of treatment, improper processing of appeals, failure to provide documentation of the evidence used to evaluate the treatment, and improper Employee Retirement Income Security Act (ERISA) appeals processing.

The plaintiff’s daughter received inpatient treatment related to mental health issues in an in-patient, sub-acute setting. While agreeing initially that the patient required inpatient treatment, UHC then denied further inpatient treatment, stating that an outpatient setting was more appropriate. UHC’s denial of the treatment came with a form letter that provided no details as to the information evaluated to reach that decision. Later appeals were also denied with a pro forma statement that included the wrong level of care and did not respect the heightened level of care necessary for ERISA insureds and under the Mental Health Parity and Addiction Equity Act of 2008 (‘MHPAEA’). Similarly, during later inpatient treatments, CIGNA also provided similar pro forma denials for inpatient treatment.

The plaintiff filed for two causes of action: 1. For recovery of benefits under ERISA and 2. In equity under MHPAEA to receive proper plan documentation, proper processing and payment of future claims, and disgorgement of wrongfully retained payments from the prior improper violation. The plaintiffs are represented by Brian S. King, P.C. No representation entered to date for the defendants.