It's not uncommon that the primary issue in many health insurance policy coverage disputes involves medical necessity. Every health insurance policy I’ve ever seen requires that treatment be “medically necessary” before an insurer has any obligation to pay expenses arising out of that treatment. While many insurers employ similar language and guidelines to evaluate what care is medically necessary, there is no uniform standard imposed on commercial insurers relating to that concept when applied to ERISA plans. There are some types of coverage federal and state law mandate (such as WHCRA, COBRA, HIPAA restrictions on pre-existing condition exclusions, etc.), but broadly speaking, nothing prevents health insurers of ERISA plans from defining “medically necessary” care in a narrow manner that gives the insurer quite a bit of room to deny payment for medical care that would appear medically necessary to the average person.
There are many circumstances where the line between medically necessary treatment (covered) merges into care that is cosmetic, or custodial or for the convenience of the insured (excluded). A good example of the disputes that can arise is the Toman v. Goldman Sachs case found here
The line between treatment that is medically necessary and treatment that is not becomes even more blurry in situations involving mental health care. This is, in large part, due to the subjective, relatively difficult to measure and evaluate, nature of mental health problems. For a child who complains of severe arm pain after falling off his skateboard, whether the arm is broken and needs surgery is relatively straightforward: take an X-ray and have it reviewed by competent medical personnel. The same cannot generally be said for individuals suffering from mental, emotional and behavioral problems. In those cases disputes commonly arise between treating physicians and insurers about the nature of the diagnosis, the severity of the symptoms, and the appropriate level and duration of care.
The U.S. Department of Health and Human Services, Substance and Mental Health Services Administration has posted a very interesting and enlightening table on its website, which you can find here
, that outlines different methods of evaluating what care is medically necessary in the context of mental health treatment. It’s a fascinating document that contains a wide variety of perspectives of what medical necessity should mean when applied to mental healthcare. It’s also an example of the informational treasures you can find by poking around on various government websites. The internet: it’s a wonderful thing.
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