Mental Health Claim Denials in California
Many adults in America with a mental illness do not receive the medical treatment they need. Some of the major barriers to treatment are the cost of treatment and insurance denials. If your health insurance company recently denied a mental health claim, it is important that you know you have options. A Los Angeles mental health claims denial lawyer can help you get coverage for the treatment you need. A dedicated insurance denials lawyer understands the system and can use their knowledge to help you.
$3 Million Case Result Dealing with Eating Disorder & Mental Health Coverage
The Mental Health Parity Act
Mental health parity means the same coverage for mental health care as other types of health care. Under California and federal laws, including California Health & Safety Code § 1374.72, health insurance companies cannot legally limit mental health care more than they limit physical health care. This applies to both diagnosis and treatment as well as outpatient and inpatient hospital services and prescription drug coverage. For instance, an insurance carrier cannot place a cap on mental health visits per year if they do not place the same cap on physical health care visits.
Under California law, the following conditions must be treated under health insurance plans:
- Schizophrenia
- Bipolar Disorder (manic-depression)
- Major depressive disorders
- Obsessive Compulsive Disorders
- Pervasive developmental disorders
- Anorexia nervosa
- Bulimia nervosa
- Panic Disorders
- Substance Abuse
These conditions may be treated in a variety of ways, including counseling, an intensive outpatient program, a partial hospitalization program, and a residential treatment center program. When a health insurance carrier denies a claim for treatment of any one of these conditions, the policyholder has options. A Los Angeles mental health claims denial lawyer can work to get them the coverage they need.
2020 Update
California’s legislature passed the Mental Health Parity Senate Bill 855 and Governor Newsom signed this bill into law. This bill requires health insurers to cover a broader group of mental illnesses including addiction and substance abuse. “This would make CA the nation’s leader on mental health and addiction coverage,” said a group co-sponsoring the bill. Read more about this bill and the mental health benefits it added.
Information from the Centers for Medicare and Medicaid Services found that across all U.S. Affordable Care Act health insurance plans in 2020, 20% of the medical necessity denials were for behavioral health services.
2022 Update
On July 1st, 2022, a new California state law went into effect, aiming to remedy one of the largest issues in our health care system – long wait times for mental health care. The new law, introduced as Senate Bill 221, requires health insurance companies to provide access to follow-up mental health care within ten days of the initial appointment. The passing of SB 221 amends Sections 1367.03 and 1367.031 of the Health and Safety Code, and amends Section 10133.53 and adds Section 10133.54 to the Insurance Code.
Why are Medical Care Delays Common?
Too often, a person seeks medical health care only to discover that scheduling an appointment isn’t as easy as it should be. Some doctors may no longer take their insurance, some may not be taking new patients, and the doctors who are taking new patients may not have any availability. Most people can’t wait that long for care, and they shouldn’t have to. Especially after our experiences with the COVID pandemic over the last few years, we know how scary it can be when you need to see a doctor but can’t.
Why are medical care delays such a common problem? Long wait times typically occur when an insurer doesn’t keep a network of doctors sufficient enough for the number of its policyholders. Each health insurer contracts with providers or groups of providers in a certain area to provide care to its policyholders. Insurers guarantee a steady source of patients to the healthcare providers. In return, healthcare providers offer discounted rates to the health insurers. Certain plans like PPOs allow policyholders to see out-of-network providers at a higher cost. However, with plans like HMOs or EPOs, policyholders must receive care in-network. With these plans, a reliable and sizable network of providers is essential. (Learn more about types of health care plans here). If there aren’t enough doctors or aren’t the right kind of doctors available in-network, a policyholder may have no other choice but to wait until one becomes available.
What Has the State of California Done in the Past to Remedy This Issue?
The State of California has made several efforts to remedy this issue. The Knox-Keene Health Care Service Plan Act of 1975 gives authority to California’s Departments of Managed Health Care and Insurance to develop regulations for health insurance companies. These departments have set regulations that require insurance companies to provide timely access to care and provide guidelines on how they may achieve this. Currently, based on department regulations, health insurance companies are required to maintain provider networks that have the capacity and availability of licensed health providers to meet the needs of their insured within a specific timeframe. These regulations stipulate that for nonurgent issues, an insurance company must be able to provide a policyholder an appointment within ten days of the policyholder’s request. This regulation includes appointments with mental health care providers.
Unfortunately, timely access regulations are not as strict for mental health care. An initial appointment must be provided within 10 business days of the initial request. However, there is no set timeframe for scheduling a follow-up appointment. So while you may have that first appointment with a mental health professional, you may have to wait several more months before you can start your actual treatment. Providers complain that their schedules are so full of first appointments in order to satisfy state regulations that they have no time to continue care, or to schedule reliable weekly appointments with returning patients. For mental health care specifically, the problem of wait times has not been resolved, simply displaced.
How Does Senate Bill 221 Address These Mental Health Care Appointment Delays?
Senate Bill 221 aims to remedy this unfortunate oversight. Firstly, these regulations, which were developed and adopted by the Department of Managed Health Care as well as the Department of Insurance, will be codified into law, making the willful violation of these regulations a crime. Secondly, it has added further requirements—health insurers must provide follow-up appointments for mental health care within ten days of the initial appointment.
These new requirements put the responsibility on health insurance companies to maintain adequate provider networks. If an insurer cannot provide timely access to care, then it is failing to uphold its part of the deal with policyholders. We don’t pay for health insurance only to be forced to wait months for care. SB 221 hopefully fixes this oversight and allows people who desperately need care to receive it in a timely manner.
Insurance Companies in Los Angeles Not Covered
The Mental Health Parity Act only applies to state-regulated health care service plans and insurance plans that are regulated by the state. Self-funded plans, such as those that are through large employers or unions, are not included under this Act. Medicare, Veterans Administration Programs, and Medi-Cal are also not included.
However, Federal parity laws may apply to some plans or programs that are not mandated by California’s Mental Health Parity Act. A Los Angeles mental health claims denial attorney can help insured individuals determine whether their health insurance benefit plan falls under Federal or California Health Parity laws.
What to Do After a Mental Health Care Denial
Insured individuals do have options if their mental health claim is denied by their insurance carrier. They can file a formal complaint with their health insurance provider. Under federal laws, the health insurance company should have a formal way of reviewing and addressing these complaints.
Depending on the type of plan, they may be able to appeal the decision at least once, if not twice. However, whenever a claim is denied it is best to consult a Los Angeles mental health claims denial attorney who can review the policy and help determine the best path forward.
How a Los Angeles Mental Health Claims Denial Attorney Can Help
A Los Angeles mental health claims denial lawyer can work to help you get your mental health claim accepted and paid. A lawyer who is well-versed in federal and California insurance laws can use their knowledge to help you seek justice when it comes to mental health claims.
If your insurance company denied a mental health claim, contact our offices today. We can examine the circumstances surrounding your claim to determine the best course of action to take. We work with people who are denied counseling, intensive outpatient programs, residential treatment center programs, and more.
Summary of a Case That We Filed
In addition to this example case summary, please view a full list of our results and client testimonials.
- We filed a case against New York Life Insurance Company for unreasonably denying our client’s claim for long-term disability benefits. Our client’s life was forever changed when he experienced a very traumatic event. This traumatic experience caused our client, a successful professional, to suffer from serious mental health issues, including post-traumatic stress disorder, depression, anxiety, and suicidal ideation. He has been unable to work due to his severe mental health struggles, but New York Life has unreasonably denied his claim for long term disability benefits, despite being contractually obligated to provide them. In addition, New York Life forced our client to undergo a biased Independent Medical Examination, which worsened his mental health issues and inflicted emotional distress on him. We are suing New York Life Insurance Company for, among other things, breach of the implied covenant of good faith and fair dealing, and breach of contract.
We Take Pride in Representing People With Mental Illness
We have a track record of representing both adults and children living with mental illness throughout California in legal actions. Many of these suits have been against the largest insurers including Anthem Blue Cross, Blue Shield of California, Kaiser, HealthNet, and others, for coverage of mental health services. For example, we represented a young man living with obsessive-compulsive disorder who brought suit in Los Angeles Superior Court on behalf of himself and thousands of Kaiser members living in California with a severe mental illness against Kaiser for its deficient mental health services. The suit hoped to end Kaiser’s policy of denying regular individual psychotherapy for those living with mental illness.
We are grateful that we can continue to represent those living with mental illness who are being taken advantage of by others.
