James's daughter, C.F., had serious mental, emotional and behavioral problems that required acute inpatient mental healthcare. When she had stabilized her treating doctors recommended that she be treated inpatient on a sub-acute basis at a residential treatment center. Her parents admitted her to Island View Residential Treatment Center. CIGNA Behavioral Health (CBH) refused to authorize coverage for Island View asserting that C.F.'s condition did not satisfy CBH's internal medical necessity criteria. Thus, CBH said C.F.'s residential treatment was not covered.
James retained me to represent him and we brought suit against CBH to recover the unpaid medical expenses. Judge Kimball reversed CBH's denial. He ruled that CBH had utilized improper criteria in evaluating C.F.'s condition. He also faulted CBH for cherry picking C.F.'s medical records and ignoring the opinions of her treating physicians. Finally, CBH attempted to present for the first time in litigation reasons it denied the claim. Because these reasons had never been communicated to the family when the claim was initially denied, the court refused to consider them. The court ordered CBH to pay C.F.'s residential treatment at Island View.
I wish I could say that how CBH treated C.F.'s residential treatment claim was uncommon. But the fact is that insurers regularly use improper criteria to evaluate coverage of residential treatment.
Join The Conversation
Post A Comment
Articles
- Posted on 05/17/2011 CIGNA v. Amara
- Posted on 03/29/2011 Bloomberg Markets' article on ERISA
- Posted on 12/24/2010 James F. v. CIGNA Behavioral Health Inc.
News
- Posted on 07/11/2019 Timothy D. v. Aetna Health and Life Ins. Co.
- Posted on 06/24/2019 Family says insurance fails to pay for mental health coverage despite medical necessity
- Posted on 04/24/2006 Eliminating Discretionary Clauses in Insurance Policies