Wit v. United Behavioral Health I

Brief Filed: 4/22
Court: U.S. Court of Appeals for the Ninth Circuit
(three-judge panel)
Year of Decision: 2022

Read full-text amicus brief (PDF, 212KB)opens in new window

Whether a health insurer is in violation of the Employee Retirement Income Security Act (ERISA) if it ignores generally accepted medical standards and uses its own cost-based guidelines when making determinations on which behavioral health services will be considered “medically necessary” and thus covered by the plan.

ERISA; Mental Health Parity

In 2019, a judge for the United States District Court of Northern California issued a landmark decision in the case of Wit v. Behavioral Health Care (UBH). In its decision, the district court held that UBH had violated ERISA by inappropriately denying plaintiffs’ behavioral health claims. The court held that UBH must provide coverage that aligns with the generally accepted standards of care as developed by professional medical associations and the medical community—instead of prioritizing its own financial bottom line. The district court also ordered UBH to reprocess previously denied claims under the new guidelines.

APA assisted the National Association of Behavioral Health (NABH) in drafting an amicus brief to the Ninth Circuit. The brief contained strong arguments in support of policies for parity of mental health care, asserting that finding in favor of UBH would result in the restriction of patients’ ability to access to the appropriate care for mental health and substance use disorders

In March of 2022, a three-judge panel of the Ninth Circuit of US Court of Appeals overturned the district court’s decision, holding UBH’s method for determining coverage was “not unreasonable.” However, in January of 2023, the same three-judge panel issued a corrected ruling, affirming in part and reversing in part the decision of the district court. This new ruling affirmed that the plaintiffs did have standing to bring their claims and that the district court did not clearly err in finding that UBH had a conflict of interest due to UBH serving as both plan administrator and insurer. However, the Court determined that, even if the conflicts of interest were of a level warranting suspicion, UBH’s interpretation did not conflict with the plain language of the plan and that the district court erred when it substituted its own judgment for that of UBH’s when it decided that UBH’s guidelines improperly deviated from the generally accepted standards of care. Instead, the panel held that the district court should have shown greater deference to UBH’s interpretation. The panel also held that the district court’s order for UBH to reprocess nearly 67,000 claims under the new guidelines, was an abuse of the district court’s discretion, reasoning that the reprocessing of claims was not a remedy in and of itself, but the means to a remedy, and thus unavailable to plaintiffs under ERISA.