In recent years, the practices of major health insurers like UnitedHealthcare have come under intense scrutiny for their methods of denying coverage for mental health treatments. Investigations have revealed that these companies often employ doctors whose judgments have been repeatedly criticized by courts, raising significant legal and ethical concerns. A recent ProPublica article tells the story of Emily Dwyer and highlights these issues.
A Case of Denied Treatment
In the case of Emily Dwyer, a 15-year-old with severe anorexia, UnitedHealthcare denied continued residential treatment coverage. Despite clear signs of her ongoing struggles, including concerning behaviors like over-exercising and refusing to eat meals, three separate physicians working on behalf of the insurer claimed that Emily no longer exhibited these behaviors. Based on their evaluations, UnitedHealthcare terminated coverage for the treatment that was crucial for her recovery.
Similar to the Dwyers, many Americans have received mental health treatment denials from their insurance companies, even with clear evidence of ongoing needs. While most patients accept their losses, a few, like the Dwyers, take their fight to federal court. In this case, their persistence put a spotlight on some critical flaws in the insurer’s processes.
The Role of Company Doctors in Denying Care
Insurance companies frequently rely on internal or contracted physicians to assess claims for mental health treatments. However, these assessments do not always thoroughly review patients’ medical histories. In Emily’s case, her family appealed the denial in 2016. Dr. Barbara Center, a psychiatrist referred by UnitedHealthcare’s law firm, spoke with Emily’s primary care provider, who pleaded for the continuation of Emily’s treatment. Despite this, Dr. Center upheld the denial.
Under sworn deposition, Dr. Center admitted that she had not reviewed Emily’s complete medical records before making her decision. Typically, she only reviews information provided by the insurer. In Emily’s case, UnitedHealthcare did not send her full medical records.
An analysis of Dr. Center’s past reviews revealed a trend. Over the previous three years, her rate of recommending denials was around 90%, compared to an overall denial rate of about 55% for other reviewers. While a spokesperson for UnitedHealthcare’s law firm claimed that advisory opinions do not usually determine coverage decisions, it still raises serious questions about the thoroughness of the insurer’s review process.
The Battle to Overturn Denied Coverage
In 2017, nearly two years after the original denial, Emily’s family sued UnitedHealthcare for wrongfully denying coverage. Initially, the court ruled in favor of the insurer. However, the Dwyers appealed, and five months later, the 5th U.S. Circuit Court of Appeals reversed the decision. The appellate court unanimously ruled in favor of Emily’s family, recognizing the insurer’s failure to adequately justify its denial.
This victory not only provided Emily’s family with the justice they deserved but also brought the urgent need for systemic changes in how insurers handle mental health claims to the forefront.
The Need for Reform
Emily’s case emphasizes the pressing need for systemic reform in the healthcare industry. Insurers must be held accountable for their denial practices and ensure that decisions are based on thorough, unbiased medical evaluations. A proposed key to reform would require insurers to rely more heavily on the opinions of doctors who are actively treating patients rather than those contracted by the insurer.
Additionally, implementing transparent review processes and allowing for independent oversight of denied claims can help safeguard patients’ rights to necessary treatments. Although resources are limited, regulatory bodies should enforce stricter guidelines to prevent insurers from prioritizing cost savings over patient well-being.
The denial of mental health care based on questionable medical reviews, as seen in Emily Dwyer’s case, highlights the significant legal and ethical challenges posed by these practices. The healthcare industry must place patient well-being above cost-cutting measures. Ensuring fair and thorough evaluations for treatment coverage is not just a legal obligation but a moral standard. By prioritizing transparency and accountability, the healthcare system can better protect the lives of those it serves and rebuild trust with patients and their families.
If you or a loved one has a potential case, contact Bell Law Firm for a free consultation.