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Judge Orders 67K UnitedHealthcare Claims Reprocessed

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UnitedHealthcare sign. (Photo: Shutterstock)

What does a federal magistrate judge do on Election Day?

Well, if you’re U.S. Chief Magistrate Judge Joseph Spero in San Francisco, you put the finishing touches on a 99-page order hitting UnitedHealthcare, the nation’s largest health insurer, with an injunction requiring the company to revisit about 67,000 denials of claims for mental health and substance abuse coverage.

Spero on Tuesday reaffirmed a finding from last year where he found the guidelines that UnitedHealthcare used when making coverage decisions didn’t provide for generally accepted standards of care outlined in the plaintiffs’ health insurance policies.

In his prior ruling, Spero found that United Behavioral Health (UBH), which manages behavioral health services for UnitedHealthcare, breached its fiduciary duty to policyholders by following guidelines that emphasized cost-savings and addressing acute problems rather than treating underlying issues.

“UBH engaged in this course of conduct deliberately, to protect its bottom line,” Spero wrote Tuesday.

Spero’s latest order grants a request from the plaintiffs’ team at Zuckerman Spaeder and Psych Appeal for an injunction designed to prevent UBH from harming class members in the same way going forward—an injunction that could be in place for up to 10 years.

UBH is required to reprocess all of the claims that were denied based on the flawed internal guidelines under the watchful eye of a special master, who will also be tasked with making sure that UBH provides proper training for its claim reviewers.

The parties have been asked to jointly put together a slate of three possible special masters in the coming weeks, or alternatively, pitch their own independent lists of candidates if they can’t come to an agreement.

Zuckerman Spaeder health care practice head D. Brian Hufford said in a phone interview Tuesday that the ruling “reflects the court’s appreciation for the extent of the problem here and the fact that he found that United had not been upfront about their conduct.”

“United was putting its financial interest over the people that it actually owed fiduciary duties to,” he added.

Eric Hausman, a spokesman for UnitedHealthcare said via email that the company has taken steps over the past several years “to improve access to quality care by enhancing coverage through clinician-developed, evidence-based guidelines, expanding our network of providers, and providing new ways for people to quickly access care through telehealth and other digital platforms.”

“We are focused on ensuring our members get the quality, compassionate care they need, and will continue working closely with people across the behavioral health community on this important issue,” he said.

The ruling continues a string of successful results targeting insurers’ coverage decisions spearheaded over the past half dozen years by Zuckerman’s Hufford and Meiram Bendat, founder of Psych Appeal, who holds a master’s degree in clinical psychology and a PhD in psychoanalytic science as well as a JD.

The pair were the subject of a Lit Daily profile last year where my predecessor wrote their work “may single-handedly have done more to force insurers to comply with their mental health and substance use disorder coverage obligations than anyone else in the country.” And that was before Tuesday’s doozy of an order.

On Tuesday, both Bendat and Hufford spoke glowingly of each other, with Hufford calling it “a match made in heaven.”

“I’ve obviously been able to uncover clinical defects in guidelines,” says Bendat. “The Zuckerman team, and Brian in particular, really have a cutting edge skill set when it comes to managing litigation day-to-day.”

Hufford, for his part, said his stock line for headhunters calling in hopes of recruiting him to other big firm healthcare positions is this: “Well, I don’t think I’m the right person for you because I sue insurance companies.”

Meiram Bendat, of Psych Appeal, left, and D. Brian Hufford, of Zuckerman Spaeder, right. Meiram Bendat, of Psych Appeal, left, and D. Brian Hufford, of Zuckerman Spaeder, right.

Both are clearly proud of what they’ve accomplished. Bendat says that the UHB case before Spero was the first time they had shifted from bringing claims that insurers weren’t following their own guidelines in coverage decisions, to targeting the flaws of the underlying guidelines themselves.

On that point, he says that states have started to take notice. In California, Bendat helped author SB 855, a bill that went into effect this year requiring insurers to base coverage determinations to “current generally accepted standards of mental health and substance use disorder care.”

“The nice thing is that no matter what happens on appeal in these cases, the states are realizing the importance of the generally accepted standards of care and changing the law,” Bendat said.

Hufford added that after a 10-day trial and Spero’s “detailed and exhaustive” decisions, he’s confident the judge’s rulings will be upheld by the Ninth Circuit.

“I think this is going to have a huge impact of showing how you can really use the law to advance the interests of people with behavioral healthcare needs,” Hufford said.