One of our clients is a 21 year-old woman, who has struggled with anorexia nervosa since she was 12 years old. In 2009, her condition had deteriorated to the point that she entered a residential treatment center. Her insurance, which is administered by United Behavioral Health (UBH), initially authorized her treatment, but after only two and a half weeks, UBH denied further treatment on the grounds that she could be treated in a day treatment program. Our client left residential treatment and enrolled in such a program, but, after only 10 days, UBH denied further treatment.
Throughout 2010, our client’s condition further deteriorated, until she was only 74 percent of her ideal body weight. Knowing that she needed residential treatment and fearing that UBH would again deny such treatment, our client raised enough money from internet fund raising and from her parents to pay for eight weeks of residential treatment.
Our client again entered a residential treatment center in November 2010. As in 2009, UBH initially approved her treatment, but then denied further treatment after only a few weeks. This time, however, our client she retained our firm and we filed a request for an independent medical review with the California Department of Managed Health Care (DMHC), supported by declarations from her doctor and therapist explaining why she needed residential treatment. While the request was pending, our client paid for continued treatment with the money she had raised.
The independent medical reviewer agreed and, on February 22, 2011, the DMHC ordered UBH to pay for our client’s treatment. The independent medical review found that residential treatment was medically necessary from the date of UBH’s denial in December 2010 and that UBH had to pay “for additional services while the patient prepares to transition to a lower level of care.” The DMHC gave UBH five working days to implement its decision. Incredibly, at the end of the five working days, UBH again denied our client further treatment.
Luckily, after the DMHC’s decision, we had filed a lawsuit against UBH for the emotional distress its conduct had caused our client. The day after the lawsuit was served on UBH, it reversed its decision and authorized further residential treatment. However, after only 10 more days, UBH again denied further treatment.
California law requires that UBH reimburse our client for the money she had paid for her treatment within five working days of the DMHC decision overturning UBH’s initial denial or face a $5,000 a day fine. Incredibly, though it is now over 30 days after the DMHC’s decision, UBH has still not paid.
We will vigorously pursue the lawsuit on behalf of our client to recover the monies she is owed and compensation for the emotional distress and other damages caused by UBH’s outrageous conduct.