Parents Hit Blue Shield With Class Action Lawsuit Over Coverage

By Victoria Kim 07/19/17

Blue Shield of California is being accused of unfairly denying mental health treatment and addiction treatment to teens.

Angry couple claiming to a businesswoman at office

A group of California parents have filed a class action lawsuit against Blue Shield of California—accusing the health plan provider of denying coverage for mental health and substance use disorder treatment.

The parents say their teenage children were unfairly denied coverage by Blue Shield’s claims administrator based on guidelines not disclosed to patients. 

Charles Des Roches of Salinas, California, is suing on behalf of his 15-year-old son who suffers from emotional and drug problems including severe depression. The Los Angeles Daily News reports that Blue Shield refused to help pay for his medical bill, which amounted to “tens of thousands of dollars” after he was admitted for urgent treatment at a Southern California rehab. 

Los Angeles County resident Sylvia Meyer’s 18-year-old son was also denied coverage for intensive outpatient psychiatric services after he was admitted to the hospital for mental health and drug problems.

According to the lawsuit, filed in the U.S. District Court for the Northern District of California, the plaintiffs want Blue Shield to “reprocess thousands of mental health and substance use benefit denials.”

The San Francisco-based Blue Shield serves over 4 million health plan members and 65,000 doctors throughout California.

When determining coverage, insurers refer to their own set of standards, often leaving patients in the dark, the Daily News notes. 

“The process is often not transparent, conflicts are not disclosed, and the standard is generally more restrictive which suggests a focus on cost, rather than patient outcome,” said Dr. Anita Everett, president of the American Psychiatric Association.

The “internal guidelines” followed by Blue Shield’s claims administrator “allowed them to justify denying coverage when it should have been provided,” said D. Brian Hufford, a lawyer representing the plaintiffs.

Informing plan members when an insurer’s guidelines are more restrictive than usual would allow them to make informed decisions, rather than keeping them in the dark, Everett told the Daily News.

The lawsuit is part of a national strategy by law firms to ensure that insurers are not unfairly denying coverage for mental health treatment. Another company, United Behavioral Health, was also hit with a class action lawsuit for its questionable coverage criteria.

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