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UnitedHealth Group Inc. must face litigation that it illegally restricted a CBS Sports Network employee's coverage for mental health expenses, a federal appeals court has ruled.
Jonathan Denbo, a New York-based brand marketing and strategy director at CBS Sports Network, and the New York State Psychiatric Association sued UnitedHealth and several subsidiaries in 2013, alleging that the Minnetonka, Minnesota-based health insurer violated federal laws by applying more restrictive coverage terms for mental health benefits than it applied to medical benefits.
Mr. Denbo — who suffers from dysthymic disorder, a type of depression, and generalized anxiety disorder — and the association alleged that UnitedHealth improperly denied coverage for his regular outpatient psychotherapy sessions with an out-of-network psychologist following a medical necessity review.
“In determining the medical necessity of Denbo's psychotherapy sessions, moreover, UnitedHealth applied review standards that were more restrictive than both generally accepted mental health standards and the standards United applied to medical claims under the CBS plan,” Mr. Denbo alleged.
The federal court dismissed the case, ruling that UnitedHealth cannot be held liable under the Mental Health Parity and Addiction Equity Act of 2008 and the Employee Retirement Income Security Act because it provides only third-party administrative services that support CBS Sports Network's self-insured group health plan.
Mr. Denbo and the association appealed.
On Thursday, a three-judge panel of the 2nd U.S. Circuit Court of Appeals in New York unanimously reversed the lower court's ruling.
“Here, UnitedHealth appears to have exercised total control over the CBS Plan's benefits denial process,” Judge Raymond Lohier wrote in the court's 23-page opinion. “It enjoyed 'sole and absolute discretion' to deny benefits and make 'final and binding' decisions as to appeals of those denials. And assuming that United's actions violated Mr. Denbo's rights under ERISA, UnitedHealth is the only entity capable of providing direct relief to Denbo.”
The 2nd Circuit panel also reversed the lower court's ruling that the New York State Psychiatric Association does not have standing to sue in this case.
“We consistently help people access proven mental health and substance abuse treatments to ensure they get the right care at the right time in the right setting,” a spokesman for UnitedHealth said in an email to Business Insurance. “While we are still reviewing the decision, we believe this opinion is inconsistent with the way this court has addressed similar cases in the past, so we are evaluating our options for further action.”
A growing number of employers have observed a persistent if not worsening workplace stigma associated with mental and behavioral health issues, according to a recent study by the Disability Management Employer Coalition.