Washington-based health insurer Regence BlueShield must pay for a suicidal teenager’s stays in out-of-state psychiatric facilities, but it doesn’t have to change the way it evaluates claims, a federal judge ruled ( H.N. v. Regence BlueShield , 2016 BL 430149, W.D. Wash., No. 2:15-cv-01374 RAJ, 12/23/16 ).
The teen’s parents challenged Regence’s denial of coverage for three trips to Texas and Utah psychiatric facilities, which the insurer claimed weren’t medically necessary under the terms of her father’s health plan. A federal judge on Dec. 23 found that the teen’s severe depression, suicidal tendencies and propensity for self-harm made the treatment medically necessary and thus covered, but he declined the family’s request to force a change in Regence’s policies for evaluating the necessity of long-term residential care.
The dispute centered on Regence’s use of the Milliman Care Guidelines, which are evidence-based clinical guidelines used by insurers to evaluate benefit claims. The teen’s parents accused Regence of relying too heavily on the guidelines and not giving proper weight to other factors, such as the opinions of their daughter’s treating physicians.
The judge found that Regence overemphasized the Milliman guidelines in this case, but he found no evidence that the insurer had a practice of using them to summarily deny other claims. Given this, the judge ruled for the teen’s parents on their individual claims but declined to force Regence to change its policies going forward.
Judge Richard A. Jones of the U.S. District Court for the Western District of Washington wrote the decision.
Keane Law Offices represented the family. Karr Tuttle Campbell represented Regence.
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Text of the decision is at http://www.bloomberglaw.com/public/document/HN_v_Regence_BlueShield_No_15CV1374_RAJ_2016_BL_430149_WD_Wash_De.
Copyright © 2016 The Bureau of National Affairs, Inc. All Rights Reserved.
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