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Health management company found liable for ERISA violations

One federal court decision could affect the way that health insurance benefits treat employee mental health claims in Washington, D.C., and across the country. In the case of Wit v. United Behavioral Health (UBH), a managed health care company was found responsible for denying tens of thousands of workers' insurance claims for mental health or substance abuse treatments. UBH oversees behavioral health services for a number of health insurance companies, including UnitedHealthcare.

Eleven plaintiffs filed suit against UBH on behalf of over 50,000 people whose claims were denied. They alleged, and the court agreed, that these denials were based on flawed criteria. In one case, a plaintiff made out-of-pocket payments of nearly $30,000 for health care treatment despite having valid health insurance throughout that time. The court said that UBH's guidelines were unreasonable and designed to restrict access to care, rather than making use of standard, evidence-based medical guidelines to determine the necessity of treatment. The case was filed as an ERISA benefits claim, making use of the protections of the Employee Retirement Income Security Act of 1974.

This law governs the conduct of insurers in group policies issued by private companies for their employees. The law requires plan administrators to serve as fiduciaries when overseeing employee benefit plans. This means that they must run the plans responsibly for the benefit of the covered employees. In this case, UBH was found liable for breaching those fiduciary duties to the plan members by using flawed criteria to inappropriately deny coverage for treatments.

Employees who are covered by group health insurance but continue to face claim denials or apparently unfair treatment by their benefits provider may be dealing with a violation of ERISA. An ERISA benefits claims attorney can review the situation and recommend the next steps to move forward and pursue justice.

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