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Saturday, May 25, 2024 | Back issues
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Aetna’s Coverage Denial Deemed no Technicality

(CN) - Families who failed to show that Aetna Life Insurance denied coverage for mentally ill teens have a month to amend their claims, a federal judge ruled.

The class action filed in June said Aetna refused to cover patients admitted into mental health care facilities that did not provide a licensed health care professional on-site, 24/7.

The lead plaintiffs, whose names are abbreviated in the court record, called this reasoning a bogus technicality in violation of the Employee Retirement Income Security Act.

"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 stated.

Aetna sought dismissal based on its contention that the plan clearly describes two distinct requirements that facilities must fulfill for patients to be covered.

"The central issue is whether coverage under defendant's policies requires a licensed 'Behavioral Health Provider/Practitioner' [BHP] to be on-site 24/7 at the residential treatment facility, in addition to the facility being licensed to provide on-site mental health services," U.S. District Judge Samuel Conti explained Tuesday.

Conti noted that there would be no reason to mention the 24/7 provision within the language of the plan if the only requirement for coverage is that the facility itself be licensed by the state where it operates.

"If the licensed residential treatment facility is itself the on-site licensed organization per the definition of BHP, as plaintiffs submit, then there would be no reason for the plan's language to include the 24/7 exclusion because satisfaction of the plan's licensing would always satisfy the 24/7 BHP requirements," Conti wrote. "Plaintiff's reading would render the plan's distinct requirement nugatory and incomprehensible, since it would not account for defendant's having clearly set out two different provisions and defined terms in the requirements."

The plan language is therefore "not ambiguous," Conti wrote, finding the plaintiffs' arguments based on "far-fetched and illogical readings of the plans in relation to the law."

Conti dismissed the action without prejudice, giving the plaintiffs 30 days to amend their complaint.

The plaintiffs in the San Francisco case are Elizabeth and James L., their daughter Olivia; and L.M. and N.M. as guardians of M.M. Both Olivia and M.M. were about 16 at the treatment for which Aetna denied coverage.

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