Ohio Class Slams Anthem Over Mental Health Exclusion

CINCINNATI (CN) – A class-action lawsuit filed Wednesday accuses Anthem of violating Ohio’s mental health parity law by denying insurance coverage for mental health treatment provided at residential facilities.

Brian Emch, lead plaintiff in the complaint brought in Cincinnati federal court, alleges Anthem Blue Cross and Blue Shield has refused to cover his son’s treatment for schizophrenia, which was provided at a skilled nursing facility, through an illegal exclusion in its policy.

“In section 6 of the plan under the heading ‘Non Covered Services/Exclusions,’ Anthem attempts to exclude coverage for treatment in a residential treatment facility by including ‘[c]are provided or billed by residential treatment centers or facilities, unless those centers or facilities are required to be covered under state law,’” the complaint states.

Emch, represented by Robert Sparks with Strauss Troy in Cincinnati, says this exclusion violates the Ohio parity law “because its blanket exclusion for services rendered at residential treatment programs is a separate treatment limitation applicable only to mental health benefits.”

The state’s mental health parity law, in part, requires that “every policy of sickness and accident insurance shall provide benefits for the diagnosis and treatment of biologically based mental illnesses on the same terms and conditions as, and shall provide benefits no less extensive than, those provided under the policy of sickness and accident insurance for the treatment and diagnosis of all other physical diseases and disorders.”

Emch claims to have paid over $29,000 from June through September 2015 for treatment of his son’s mental health disorders at Hopewell, a residential treatment center.

He says Anthem denied his insurance claims but did not “challenge the medical necessity of the services.”

“Anthem maintains that its exclusion of services provided by residential treatment centers applies equally to medical/surgical benefits and mental health benefits,” the lawsuit states. “However, the plan’s definition of a ‘residential treatment center’ clearly includes only services which are not medical/surgical. The plan defines a residential treatment center as one which provides ‘individualized and intensive treatment in a residential facility, including observation and assessment by a provider weekly or more frequently, an individualized program of rehabilitation, therapy, education, and recreational or social activities.’”

Emch seeks to represent a proposed class of Ohio citizens with Anthem insurance policies that exclude coverage for the treatment of mental illnesses at residential centers. The class seeks reimbursement for those services, as well as an order requiring coverage for all similar services in the future.

Anthem said it does not comment on pending litigation.

Emch’s attorney Sparks did not respond Thursday to a request for comment.

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