SAN FRANCISCO (CN) - Aetna insurance wrongfully denied costly claims for a girl who tried to kill herself three times and another girl who threatened to kill her psychologist, the families say in a federal class action.
The families claim Aetna rebuffed their claims because the licensed mental health facilities where the girls were staying did not have "a licensed healthcare professional ... on-site 24/7."
That's a bogus technicality, the families say.
"Under the [Aetna] plan language, if the residential treatment facility is licensed under the law of the state in which it is located to provide inpatient treatment, it qualifies as a facility that is eligible for coverage by Aetna regardless of whether a licensed healthcare professional is on site 24/7," the complaint states.
But Aetna denied both families benefits by citing the staffing provision.
"Aetna violates the terms and conditions of its own plans because it denies claims from properly licensed residential treatment facilities on the basis that the facilities do not have a licensed healthcare professional on site 24/7," the complaint states.
Both children suffered from a complex of disorders, including bipolarism, depression, anxiety and anorexia.
One tried suicide three times and was admitted into the New Haven Residential Treatment Center in Utah between June 2010 and June 2012. Her parents are from Santa Clara, Calif.
The other threatened to kill her psychiatrist and was admitted into the Waterfall Canyon Academy in Utah from October 2011 through April 2013. Her family is from Los Angeles.
Together, the families owe $248,000 in medical costs due to Aetna's denials of claims. They say other families have suffered the same rebuffs.
"The plaintiffs and proposed class members are entitled to payment for the expenses incurred arising out of the mental health care provided at residential treatment facilities for which coverage was improperly denied by Aetna," the complaint states.
Most of Aetna's health plan or health insurance policies, including the health plans or policies covering the plaintiffs, are provided through employer-sponsored welfare benefits plans that are governed by the Employee Retirement Income Security Act of 1974, according to the complaint.
Plaintiffs seek class certification, costs, declaratory judgment, an injunction and damages. They are represented by David Lilienstein.
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