Mansell, Engel & Cole

Mental health claims often denied coverage

When it comes to mental illness, many people in Oklahoma and nationwide suffer in silence. After all, while some illnesses or injuries clearly manifest themselves in ways that make it apparent that the person is hurt or sick, mental illnesses generally carry no physical monikers. Yet, this does not mean that they are no more or less serious than other types of illnesses.

Unfortunately, some insurance companies do not always see things this way. In fact, insurance claims for mental illness treatments are denied at a greater rate than other types of claims. A National Alliance on Mental Illness survey revealed that in 2015, almost 30 percent of respondents covered by private medical insurance under the Affordable Care Act had a claim for mental health care denied. The reason cited for the denial was that it was not a "medical necessity." This is more than twice as many as those whose general medical care claims are denied. When this happens, people with a mental illness are often forced into the difficult situation of either paying for mental health treatments on their own or going without treatment altogether.

Although the Mental Health Parity and Addiction Equity Act of 2008 made it mandatory that mental health claims receive coverage that is on par with other medical claims, it appears that some insurers are not following these laws. This is made more difficult due to the fact that there are also varying state laws on this topic. According to some, it is difficult to enforce the law when there are no benchmarks for clearly identifying when a mental health treatment is actually "necessary."

One way this problem can be addressed is for physicians who provide mental health care to familiarize themselves with the criteria insurance companies are using to decide whether a patient's claim is "medically necessary." This way they can use the right language to trigger coverage. There are also those who advocate for more integrated care for mental health patients. And, of course, insurance companies must comply with applicable laws.

In the end, a denied insurance claim for any type of illness can be extremely frustrating. Sometimes it may be necessary to seek legal help for denied insurance claims. An attorney can assess their client's situation, and can advocate for their clients who seek to have their medical treatments covered by their health insurance.

Source: Mic, "Why is it so hard to get mental health treatment covered by insurance? Patients face this catch-22," Kenny Herzog, Dec. 13, 2017

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