The seismic 2019 ruling in Wit v. United Behavioral Health (UBH), which compelled UBH to reprocess more than 50,000 denied claims for psychiatric conditions due to noncompliance with generally accepted standards of care and treatment, has been undone by a new opinion from the Ninth Circuit Court. (Wit v. United Behavioral Health, U.S.App.LEXIS 2039, 2023 WL 411441 – January 26, 2023)
The ramifications of the opinion
In what amounts to an alternative interpretation of standing ERISA law, the new ruling allows United to serve as an unchecked decisionmaker and funding source for behavioral health ERISA claims. The painfully obvious conflict of interest in this arrangement is a major setback for both claimants and mental health advocates.
This opinion allows United, and by extension all health insurance providers, to write their own rules for what constitutes generally accepted standards of behavioral healthcare. With their own profit margins as a primary motivator, insurance providers have little incentive to cover mental healthcare beyond short-term crisis management.
In theory, ERISA fiduciary responsibility explicitly requires insurers to act in the interest of plan participants. While we already know that insurers test this legal obligation as a matter of course, insurers now have even less reason to voluntarily satisfy this duty.
A wrong turn in the country’s ongoing mental health crisis
Anyone with any experience in behavioral health will recognize the severe shortcomings of this approach, particularly when there are two or more life-altering conditions requiring ongoing treatment, such as depression and substance abuse. Indeed, the opinion bafflingly ignores the Mental Health Parity and Addiction Equity Act of 2008.
Viewing these conditions like a broken leg, rather than the chronic diseases that they are, will have dire consequences for patients, who will now have to choose between paying out-of-pocket for prohibitively expensive ongoing treatment or going without.
An opinion built on a questionable ruling
Sadly, this opinion props up yet another impediment for behavioral health claimants.
Current ERISA law requires claimants to exhaust their appeals before resorting to lawsuits, a requirement that was established by legal entities without the input of healthcare professionals. This deeply flawed rule assumes that people with mental and/or physical ailments, which are presumably debilitating if ERISA coverage is being sought in the first place, can somehow summon the focus and energy to tackle multi-layered bureaucratic obstacle courses.
The Ninth Circuit has seemingly embraced this regrettable aspect of ERISA law to further strengthen the position of insurance providers. People coping with mental health disorders are far less likely to complete this proverbial marathon, even if they could afford the legal fees, which, again, they demonstrably cannot if they are seeking ERISA coverage.
This Tolstoy-esque story will hopefully have another chapter that course-corrects for this recent opinion. Until then, the lengthy, sadistically laborious ERISA claims process endures.