Blue Shield of California Mental Health Coverage Class Action Settlement

California Physicians’ Service d/b/a Blue Shield of California will pay $7 million as part of a settlement agreement to end a class action lawsuit accusing the company of imposing improper restrictions on participants seeking coverage for mental health treatments.

Lead plaintiff Charles Des Roches alleged in his class action lawsuit that Blue Shield of California incorrectly refused to cover costs of residential and intensive outpatient mental health and substance abuse treatment under certain insurance plans.

The plaintiff said that by refusing to cover these treatments, Blue Shield of California violated their fiduciary duty to health insurance policyholders.

The Blue Shield of California insurance class action also claims that the Blue Shield policy was inconsistent with generally accepted professional standards in the mental health and substance abuse disorder treatment community.

Blue Shield of California has agreed to provide a settlement award to policyholders who sought insurance coverage for residential or intensive outpatient treatment of psychiatric or substance use disorders whose claims were denied on the basis that they were not medically necessary based on policies challenged by the class action lawsuit.

The insurance company has also agreed to stop using the challenged guidelines, also known as the “Magellan Medical Necessity Criteria Guidelines,” for Blue Shield of California insurance policyholders.

Class Members have until June 5, 2018 to opt out of or object to the settlement.

Who’s Eligible

Class Members include Blue Shield of California policyholders who sought insurance coverage for residential or intensive outpatient treatment of psychiatric or substance use disorders between Jan. 1, 2012 and March 5, 2017, whose claims were denied on the basis that they were not medically necessary based on policies challenged by the class action lawsuit, i.e. the Magellan Medical Necessity Criteria Guidelines.

Potential Award

Reimbursement for treatments, unless the total amount for all Class Members exceeds 75 percent of the settlement fund. If that occurs, Class Members will receive a pro rata share of the settlement fund.

The plan of allocation document offers the following description of how payments will be calculated:

“1. Calculate the Class’s Total Treatment Amount. If the sum is greater than 75% of the Settlement Fund, then proceed to Paragraphs E(2)-(4) to calculate the Class member’s Pro Rata Share.

2. Divide that Class member’s Total Treatment Amount by the Class’s Total Treatment Amount (the ‘Pro Rata Percentage’).

3. Multiply the Settlement Fund by 75% to arrive at the ‘Treatment Amount Distribution Fund.’

4. Multiply the Pro Rata Percentage by the Treatment Amount Distribution Fund to arrive at the Class member’s ‘Pro Rata Share.'”

Proof of Purchase

None. Class Members can submit additional documentation if they believe that Blue Shield of California’s records understate the amount they are due under the settlement agreement.

FAQs

FREQUENTLY ASKED QUESTIONS »

NOTE: If you do not qualify for this settlement do NOT file a claim.

Remember: you are submitting your claim under penalty of perjury. You are also harming other eligible Class Members by submitting a fraudulent claim. If you’re unsure if you qualify, please read the FAQ section of the Settlement Administrator’s website to ensure you meet all standards (Top Class Actions is not a Settlement Administrator). If you don’t qualify for this settlement, check out our database of other open class action settlements you may be eligible for.

Claim Form Deadline

There is no Claim Form and no Claim Form deadline. Class Members will automatically benefit from this settlement unless they opt out by June 5, 2018.

Case Name

Des Roches, et al. v. California Physicians’ Service, et al., Case No. 5:16-cv-02848, in the U.S. District Court for the Northern District of California, San Jose Division

Final Hearing

6/28/2018

Settlement Website

www.ChallengedGuidelinesSettlement.com

Claims Administrator

Challenged Guidelines Settlement
c/o Angeion Group
PO Box 30352
Philadelphia, PA 19103
1-888-573-6825
ChallengedGuidelinesSettlement@AdministratorClassAction.com

Class Counsel

GRANT & EISENHOFER PA

ZUCKERMAN SPAEDER LLP

PSYCH APPEAL INC.

Defense Counsel

Counsel for Blue Shield:
MANATT PHELPS & PHILLIPS LLP

Counsel for HAI:
CROWELL & MORING LLP