Let’s say you have a son who develops a drug problem or becomes suicidal. His doctor says he needs extensive treatment at a residential mental health center. But your insurance company denies the coverage.
Consumers can appeal those decisions to California’s Department of Managed Health Care, which will review the insurance company’s decision and either uphold it or overturn it.
Under law, the agency has six days to complete an urgent review, upon receipt of a complete application. A lawsuit filed late Tuesday alleges that the agency routinely violates review deadlines, sometimes taking weeks or longer to render a decision.
“The consequences of not receiving a timely decision can be devastating," says Meiram Bendat, an attorney for the plaintiffs and president of Psych-Appeal, a mental health advocacy law firm. "Patients must decide whether to pay for costly treatments out of pocket, with the very real possibility of not getting reimbursed – or simply say ‘no’ and forego the care they desperately need."
The Department of Managed Health Care regulates health insurance plans that cover 25 million Californians. The number of people affected by the urgent review process addressed in the lawsuit is relatively few. Last year, the agency reviewed 1,789 insurance denials for care; 508 were handled on a expedited basis; and 15 percent of those (78 cases) were for mental health conditions.