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.