UnitedHealth ERISA Class Action Lawsuit Overview:
- Why: The plaintiffs allege UMR imposed improper guidelines while managing benefits requests, thus violating its fiduciary duty.
- Who: Two health care plan participants sued UMR Inc., a subsidiary of UnitedHealth.
- Where: The class action lawsuit was filed in Wisconsin federal court.
A federal judge certified a class of health benefit plan members who were denied mental illness or substance use disorder treatment services by UMR, a subsidiary of UnitedHealth.
U.S. District Judge William M. Conley appointed Luciana Berceanu and Judy Hernandez as lead plaintiffs of the class action lawsuit. Berceanu and Hernandez have two different health care plans sponsored by their employers and governed by the Employee Retirement Income Security Act of 1974 (ERISA). UMR is the benefit claims administrator for their plans, which allows the company to interpret the terms of each plan when it comes to claiming benefits.
Berceanu and Hernandez will represent a nationwide class of any member of a health benefit plan governed by ERISA whose request for coverage or residential treatment services for mental illness or substance use disorder was denied by UMR
Judge Conley found that there is a large enough number of individuals who share a common experience that makes them eligible for class membership. The plaintiffs submitted evidence that at least 1,600 individuals meet the class definition.
UMR Breaks Fiduciary Duty With ‘Overly Restrictive’ Plans
Berceanu and Hernandez first filed their class action lawsuit in 2019, alleging that UMR implemented “overly restrictive” guidelines in their assessments of plan benefits. In applying their guidelines, UMR also supposedly subjected the plaintiffs and class members to “arbitrary and capricious” benefits requests processes
As a health care plan administrator, UMR must comply with ERISA and act as a fiduciary, or in customers’ best interests, when making benefit determinations. The plans require that services must be consistent with “generally accepted standards of medical practice.” However, UMR adopted a different set of guidelines, known as the UBH Level of Care Guidelines.
These guidelines determine whether insurance coverage is approved or not. Under these guidelines, UBR denied patients’ requests for inpatient mental health and substance use disorder treatment, according to court documents.
Plaintiffs seek a declaration that UMR’s guidelines violated its fiduciary duties, an order to prevent UMR from continuing use of the guidelines and to adopt generally accepted standards of medical practice and for UMR to reprocess claims for residential treatment that it previously denied according to new adopted guidelines.
UMR Motion to Dismiss Denied
Judge Conley also heard UMR’s motion to dismiss the case and largely denied the motion.
In its motion, UMR argued that it “is not a proper defendant,” and that, instead, the plaintiffs should be suing the health plans themselves. Judge Conley agreed, but following precedent, denied the motion since the plaintiffs are “not seeking an award of benefits under their respective plans.” Further, Judge Conley deemed UMR’s motion to dismiss as based on “a misrepresentation or misreading of plaintiffs’ claims.”
UMR did gain one small victory when Judge Conley agreed to dismiss the plaintiffs’ claim for equitable relief. The plaintiffs “fail[ed] to articulate any equitable relief” that wasn’t already addressed in the complaint.
Were you affected by UMR’s health care plan guidelines? Tell us about it in the comments below!
The plaintiffs are represented by Caroline Reynolds, Andrew Nathan Goldfarb, Justin R. Cochran and Samantha Marie Gerencir at Zuckerman Spaeder LLP; Robert John Gingras at Gingras Thomsen & Wachs; and Meiram Bendat at Psych-Appeal Inc.
The UnitedHealth ERISA Class Action Lawsuit is Berceanu, et al. v. UMR Inc., Case No. 19-cv-568-wmc, in the US District Court for the Western District of Wisconsin.
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4 thoughts onFederal Judge Certifies Class After UnitedHealth Denies Mental Health Benefits
I am currently fighting with UMR concerning Dexcom sensors and Omnipod pods. My wife’s company started using them this year. I have been using the sensors and pods since 2020. And now they say my doctor has to have a one on one with their doctor. I run out of supplies in 2 days.
This insurance administrative service is a scam. It should be illegal. They deny almost every claim. Providers and labs refuse to accept their coverage because they don’t pay. They send customer service calls to the Philippines. If i cant use my insurance in another state without it being out of network then why do i have customer service agents in Asia. I can’t use my insurance abroad, but I have to confer with a customer ser ice agent about my claim who is located on another continent? The only people who can answer questions or resolve issues are the managers based in the U.S. They can’t reset online passwords, you have to recreate your account. It’s a circus.
I had Covid in 2020 and went to an Urgent care to be assessed for continuous fever and fatigue with cough. I was charged $300 for a chest X-ray that UMR refused to pay. I filed the appeal and sent the physician documented medical records indicating need for chest X-ray related to covid. UMR still refused to pay because they disagreed with the terminology although it was clearly spelled out without any option for confusion. They use a blanket statement about medical necessity criteria statements not being met and they dispute documentation regardless of its validity. They said that on accident once before a claim was even filed during an over the phone inquiry. Employees are coached how to respond to deny claims. I won’t sign up with them again and would rather have no insurance than use them. When I’m in need of a money furnace and a source of distress they’ll be the first organization I call.
Mine is not mental health relate, but neurological with migraine botox treatments and UMR denying/ delaying reprocessing claims every single time I have an appointment. Last year, it was 9 or 10 months before a bill was paid. My account was placed on hold over and over with my doctors office, so I
wasn’t sent to collections, and I know they were beyond frustrated with my insurance provider. My poor doctors office probably had to resubmit my claim 4 or 5 times, each time it was rejected by UMR for some reason or another. This year, as of now, my doctors office is refusing to place my account on hold for a December 22, 2021 visit, that UMR rejected with a false claim I refused to provide information. 1) I was never called, mailed, or emailed anything asking to provide information. How was I supposed to even know they wanted anything? 2) this bill was for 2021 when my information was valid, so there no reaspn it should have been denied 3) the information they wanted, was to know if I had access to any other form of health insurance, and therefor my account was suspended so UMR can keep delaying payments and properly process claims. There is always an excuse with them. Quantum Health is the middle man I speak to when calling, and it takes close to an hour on hold each time I call before I can get anyone on the phone. It’s so bad that I know each time I go to a speciaist, I will probably need to plan on 3 to 7 calls lasting 30 min to 1 hr 30 min each to battle to have a claim processed. Now, there is a chance I’m going to collections for a bill in the amount of $2384 that they denied for service on 12/22/21. I spoke to a representative with Quantum Health around January 19, 2022 and the first call I was on hold for over and hour before I was disconnected without reaching anyone. I called again and was on hold close to an hour before a gentleman answered. He said I had to verify I had no alternative means of insurance besides my husband’s employer plan, which I verified. I was not told once he verified and resubmitted my claim to UMR, it could be another 30 to 45 days for UMR to review and process the claim. I also, was not notified, when the agent reached out to my doctor’s billing department, that they refused to place my account on hold. (Probably because of all the issues they’ve had receiving payments last year). I emailed my doctor billing dept, 2/8/22 and they responded today, 2/9/22 and stated why the claim was denied (blaming me for my failure to provide information they necer requested in December/January so I had absolutely no way to prevent their denial (AKA just another way for them to delay paying a bill). I called the number on the back of my insurance card today and was on hold an hour before reaching a representative, who told me that my doctor had refused to place my account on hold when the gentle called on my behalf last month. She also advised me it could take umr 30 to 45 from the date I verified information 1/19/22 to review, and determine eligibility, and reprocess the claim, which will have me right at 4 months past the date of service. I was in tears asking the representative what so I do if my doctor gets too frustrated dealing with all the delays UMR gives them, and they send me to collections? I can’t afford the full amount. Worse we pay around 14k out of my husband’s salary for this plan. I asked if the collection agency added penalties and interest, and this hits my credit, what do I do, and how can and of thos be legal? I asked if there was anywhere I could make a complaint? Knowing this is all shady practices. Once, I can understand, but every time I see my neurologist, I have this issue. They even went as far as taking the Botox off the formulary in the fall for 2022. Ironically, when they couldn’t suggest alternative treatments for ongoing migraines and because a lot of those medications are expensive and cause seizures, and I made them aware, and I felt that their constant denial or altering what’s covered (conveniently the treatments/medications I need) seem to be revoke. I have a sleep disorder they refuse to cover medication for, so I pay out of pocket every month.