The complaint alleges that Aetna imposes a set of overly restrictive criteria to determine which residential treatment facilities are covered.
The complaint, which was filed this week in U.S. District Court in the Central District of California, alleges that Aetna illegally denied claims for mental health residential treatment services.
The complaint alleges that Aetna imposes a set of internally developed criteria to determine which residential treatment facilities receive coverage that are far more restrictive than generally accepted professional standards to “minimize the number of claims accepted and thereby maximizing Aetna’s own profits,” according to the lawsuit.
“Unfortunately, in administering the Aetna Plans, Aetna treats mental health as less important than physical health,” the plaintiff said in the complaint.
Aetna said in a letter that it was denying coverage because the facility is not accredited by an agency such as The Joint Commission, the Committee on Accreditation of Rehabilitation Facilities, the American Osteopathic Association’s Healthcare Facilities Accreditation Program or the Council on Accreditation.
“This class action claims that Aetna is not following the law because it is imposing more stringent standards for mental health providers to receive coverage than for some hospitalizations,” said attorney for the plaintiff Brian Adesman. “The standards they are using and the requirements for mental health facilities don’t exist for surgical benefits or physical health benefits. Our client appealed it, and each time Aetna came back and said `you don’t meet the requirements’ and refused to cover the cost.”