UnitedHealthcare Level of Care Guidelines Criticized Again

Last week, another court weighed in on UnitedHealthcare’s use of its Level of Care Guidelines in the use of residential treatment claims. In Bain v. United Healthcare Inc., No. 15-CV-03305-EMC (N.D. Cal. Feb. 15, 2020), the court ruled that it is settled law that UnitedHealthcare’s use of its Level of Care Guidelines were motivated by its own financial self interest.

The Bains sought residential treatment benefits for their daughter under a group health plan administered by United Behavioral Health.  UBH denied the treatment based on a lack of medical necessity. After the Bains exhausted all internal appeals, they filed suit. The parties filed cross-motions for summary judgment on the Bains’ claim for benefits under ERISA 502(a)(1)(B). 

The Bains first argued that the legal principle of collateral estoppel should apply on the issue of liability. Put another way, UBH should not be able to contest that its Level of Care Guidelines were found by the Wit court to be inconsistent with standards of care generally accepted in the mental health field.  The court rejected this approach. 

However, the court found that collateral estoppel applied to the “significant skepticism” to give to UBH’s benefit decision due to its financial conflict of interest. The court explained that even if was not immediately clear how UBH applied its Level of Care Guidelines in this case, the finding in Wit was reason to apply “a healthy amount of skepticism” to the standard of review.

The court concluded that UBH abused its discretion by denying the Bains’ benefits. It then remanded the claim back to UBH because it could not determine if the Bains are entitled to benefits based on valid guidelines or other criteria. 

What’s the takeaway lesson? If you have a UnitedHealthcare health insurance claim, and it is using the Level of Care Guidelines in your claim, there is legal authority you must know before you can adequately respond.

At Berg Plummer Johnson & Raval, we have represented clients whose health insurance claims have been denied by UnitedHealthcare. If your health insurance claim has been denied, it’s vital that you connect with a qualified attorney as soon as possible so that the claims can be properly evaluated. Get in touch with an experienced health insurance attorney here at Berg Plummer Johnson & Raval, LLP for assistance with your health insurance claim.