قالب وردپرس درنا توس
Home / Insurance / HMOs in State Limitation Upheld

HMOs in State Limitation Upheld



Plaintiff Suzanne Stone had a health care plan (the "Plan") governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001-1461, and administered by defendant U.S. Behavioral Health Plan, California, dba OptumHealth Behavioral Solutions of California (“Optum”). The plan excludes coverage for all out-of-state treatment, with the exception of emergency or urgent services in Suzanne Stone v. Unitedhealthcare Insurance Company; US Behavioral Health Plan, California, DBA OptumHealth Behavioral Solutions of California No. 19-16227, United States Court of Appeals for the Ninth Circuit (November 9, 2020) The Ninth Circuit was asked to force coverage for out of state services that violate the specified exclusion.

FACTS

The plaintiff, aware of the exclusion, sent her daughter to a state housing treatment program for anorexia nervosa. After Optum and UnitedHealthcare Insurance Company (together, "defendants") denied coverage, the plaintiff sued according to ERISA. The district court issued a summary judgment in favor of the defendant.

Both the Federal Parity Act and the California Parity Act require that health plans provide equal coverage for mental and physical illnesses. Here, the denial of coverage was based solely on the plan's exclusion of coverage for treatment outside the state, which also applies to mental and physical illnesses.

The plan, a health care organization plan ("HMO"), includes that mental health services are covered when medically necessary, approved in advance by Optum and provided at a participating facility. As relevant here, the plan excludes coverage for mental health services provided outside the service area, in addition to emergency or emergency services. The service area is defined as "

The plan similarly excludes coverage for physical health services provided outside the service area, with the exception of emergency or emergency services. As with mental health care, the service area is defined as "[the] the geographic region of the State of California where United Healthcare is authorized by the California Department of Managed Health Care to provide comprehensive services to members."

GS, the plaintiff's minor daughter, began treatment in June 2014 in an eating disorder program run by the University of California San Diego ("UCSD"). Optum approved the coverage. UCSD released G.S. on 18 July 2014 and stated that she “demanded a higher level of care at a family-based treatment housing facility. There are no known FBT residential facilities in California and she was therefore referred to the Eating Recovery Center [“ERC”] in Denver, Colorado.

Prior to GS's discharge from the UCSD, the plaintiff called Optum to inquire about state-of-the-state housing treatment centers and was told that the plan did not include treatment outside the state other than for an emergency.

The plaintiff admitted GS to the state, ERC, on July 21, 2014 and was again told by Optum that there was no coverage for treatment outside the state. The plaintiff was told that the Center for Discovery ("CFD") was a residential treatment center in California for eating disorders in adolescents. On 24 July 2014, Optum informed the ERC that the plaintiff had an HMO in California and that there was no coverage for GS's treatment at the ERC.

DISCUSSION

The Federal Parity Act requires that "benefits and treatment limitations for mental health problems should be & # 39; not more restrictive & # 39; than those for medical and surgical problems. " Danny P . v . Cath . Health Initiative 891 F.3d 1155, 1158 (9th Cir. 2018). [19659005] The plaintiff has not shown that the plan's requirement for GS to receive treatment at a residential treatment facility in California is a more restrictive restriction on treatment than restrictions on the treatment of medical and surgical problems, in fact she does not claim that the plan's geographical limitation applies unevenly to Therefore, the Ninth Circuit found that the Federal Parity Act was not violated by the defendant's denial of coverage.

The plaintiff has not provided any evidence that the plan's coverage of mental illness is less generous than its coverage of physical illness, or that exclusion for treatment outside the state limits the coverage of mental conditions, but not physical health conditions.The California Parity Act is therefore not involved here.

Since the plaintiff does not showed that the plan's requirements for state treatment are applied to mental conditions, but not to other medical conditions. The geographical limitation of the plan does not violate either the Federal Parity Act or the California Parity Act.

The ninth district upheld the district court's summary judgment in favor of the defendants in an ERISA action concerning the denial of care coverage for out-of-state housing treatment for anorexia nervosa. It also argued that the defendants' denial of coverage did not violate the Mental Health Parity and Addiction Equity Act or the California Mental Health Parity Act because the denial was based solely on the ERISA's exclusion of coverage for out-of-state treatment, which applied equally to mental and physical illness.

HMO exists to allow people to purchase cheap health insurance and can do so by limiting the availability of coverage. The treatment that GS needed could be provided in the state of California and would have been covered by the plan. However, the plaintiff decided to use the facility in Colorado that was thought to be better for GS than the one in California. She was told that there would be no coverage and ignored the fact and decided to sue for coverage that was clearly and unequivocally ruled out. She failed.


© 2020 – Barry Zalma

Barry Zalma, Esq., CFE, now limits his practice to employment as an insurance consultant specializing in insurance coverage, insurance claims management, insurance shortfalls and insurance fraud. almost the same for insurers and policyholders. He also acts as an arbitrator or mediator for insurance-related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims lawyer and more than 52 years in the insurance industry. He is available at http://www.zalma.com and zalma@zalma.com.

Mr. Zalma is the first recipient of the first annual Claims Magazine / ACE Legend Award.

For the past 52 years, Barry Zalma has devoted his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to enable insurance companies and their claims staff to become insurance claims staff.

https://zalma.com/zalmas-insurance-fraud-letter-2/ Last read two issues of ZIFL here.

Go to Barry Zalma videos on Rumble.com at https://rumble.com/c/c-262921 [1965655] Read posts from Barry Zalma at https://parler.com/ profile / Zalma / posts

Listen to Podcast: Zalma on insurance https://anchor.fm/dashboard/episodesZalma on insurance

Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg/

Go to the Insurance Claims Library – https://zalma.com/blog/ Insurance -claims libraries /

https://visitor.r20.constantcontact.com/manage/optin?v=001Gb86hroKqEYVdo-PWnMUkV7pkuOtkiv6oakpgK33CNlNAYW-WBlLCOZFtgvpSdcL7R-tsWKfMVqG6fEuvmM7Hh7gUEJ7yKOdgHDbGl_cGAU%3De-mail version of ZIFL, it is free! –


Source link