Employee Benefits News examines legal developments that impact the employee benefits and executive compensation employers provide, including federal and state legislation, rules from federal...
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.
To contact the reporter on this story: Jacklyn Wille in Washington at email@example.com
To contact the editor responsible for this story: Jo-el J. Meyer at firstname.lastname@example.org
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.
All Bloomberg BNA treatises are available on standing order, which ensures you will always receive the most current edition of the book or supplement of the title you have ordered from Bloomberg BNA’s book division. As soon as a new supplement or edition is published (usually annually) for a title you’ve previously purchased and requested to be placed on standing order, we’ll ship it to you to review for 30 days without any obligation. During this period, you can either (a) honor the invoice and receive a 5% discount (in addition to any other discounts you may qualify for) off the then-current price of the update, plus shipping and handling or (b) return the book(s), in which case, your invoice will be cancelled upon receipt of the book(s). Call us for a prepaid UPS label for your return. It’s as simple and easy as that. Most importantly, standing orders mean you will never have to worry about the timeliness of the information you’re relying on. And, you may discontinue standing orders at any time by contacting us at 1.800.960.1220 or by sending an email to email@example.com.
Put me on standing order at a 5% discount off list price of all future updates, in addition to any other discounts I may quality for. (Returnable within 30 days.)
Notify me when updates are available (No standing order will be created).
This Bloomberg BNA report is available on standing order, which ensures you will all receive the latest edition. This report is updated annually and we will send you the latest edition once it has been published. By signing up for standing order you will never have to worry about the timeliness of the information you need. And, you may discontinue standing orders at any time by contacting us at 1.800.372.1033, option 5, or by sending us an email to firstname.lastname@example.org.
Put me on standing order
Notify me when new releases are available (no standing order will be created)