SAN FRANCISCO (CN) - A federal judge has denied class certification to the plaintiffs in a lawsuit alleging Aetna Life Insurance Company stiffed policy holders seeking coverage for their children's mental health care.
The suit was filed by the parents of adolescents who were receiving care for various mental health conditions sought care at residential treatment centers (RTCs); the plaintiffs, all participants in ERISA programs, filed claims with Aetna to help cover the cost.
The company, however, denied coverage based on its Level of Care Assessment Tool, or LOCAT, which consists of a one-page scoring form and a 10-page instruction manual described as "Guidelines," explained U.S. District Judge Samuel Conti in his order. The LOCAT is used as a tool to help determine if patients received "medically necessary" care.
The plaintiffs argue Aetna did not correctly tabulate LOCAT scores in deciding whether to grant coverage to families. They are suing for violation of the Employee Retirement Income Security Act and for declaratory and injunctive relief, but have most recently made a motion for certification of two putative subclasses under Federal Rule of Civil Procedure.
The first class consists of Aetna participants and beneficiaries who, "had Aetna filled in the scoring form as required, would have qualified for reimbursement for inpatient residential treatment," Conti said in his review of the case.
The second class consists of individuals whose scoring forms contained blank dimensions, which made the difference between reimbursement or non-reimbursement, according to the plaintiffs.
Conti denied class certification for both subclasses, noting that claims are based on medically necessary determinations unique to each class member, which fails to establish commonality as required by law to qualify as a class.
"To determine whether a particular class member is eligible for RTC care, or any other level of care, the court would need to review medical records and other information specific to that member," Conti explained. "Such individualized, claim-specific inquiries are not amenable to class-wide resolutions."
He added that medically necessary determinations are not based on LOCAT scores alone, a fact underscored by an Aetna witness who said LOCAT scores "do not replace clinical judgment."
"Plaintiffs contend that Dr. Friedlander has testified that LOCAT is the only criteria Aetna uses to make medical necessity determinations ... However, Dr. Friedlander also testified that LOCAT was used 'as a guideline in addition to clinical judgment,'" Conti said. "In fact, during his deposition, Dr. Friedlander stressed the importance of clinical judgment more than once."
In the end, Conti said, Aetna could refuse coverage despite LOCAT scores.
"Even if the court were to agree with plaintiff's proposed method of tabulating LOCAT scores, and even if this method resulted in higher LOCAT scores for some of Aetna's members, Aetna could still refuse to provide those members with coverage on medical necessity grounds," he said.
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