Wit vs. United Behavioral Health (UBH) is a landmark case, potentially setting a precedent for how care will be covered for Americans seeking treatment for mental health and addiction.
In a robust and comprehensive 100-plus-page decision in 2019, the United States District Court of Northern California found that UBH was wrong to deviate from the widely accepted clinical standards of care for mental health and addiction. For the remedy, the Judge ordered UBH to reprocess upwards of 67,000 coverage claims for 50,000 patients (half of whom were children) in line with these accepted clinical standards of care. However, in March 2022, a three-judge panel of the U.S. Ninth Circuit Court of Appeals reversed the District Court’s order with a seven-page ruling, arguing that it is “not unreasonable” for insurers to determine coverage inconsistently with generally accepted standards of care. In January 2023, the same three-judge panel issued a corrected ruling that replaced the March 2022 ruling. This new ruling held that – even though UBH violated both its fiduciary duty by creating medical necessity criteria that put its self-interest ahead of plan members’ and the laws of four states – more than 50,000 individuals denied mental health or addiction coverage have no right to reprocessing of their claims.
A number of states, agencies, and advocates – including The Kennedy Forum -submitted amici objecting to the ruling, arguing its findings were contrary to decades of precedent and maintaining that the ruling would profoundly impair plan members’ rights to health coverage under federal law, emboldening insurers to make decisions out of step with clinical standards.
In August 2023, the same three-judge panel issued a third ruling vacating its January 2023 opinion and replacing it with a new opinion (1) holding that plaintiffs in the case did have standing to bring their claims forward; (2) holding that the district court did not err in certifying three classes to pursue the fiduciary duty claim, but reversing the district court’s certification of the denial of class benefits; (3) holding that the district court erred to the extent it determined that the ERISA plans required UBH’s care utilization review guidelines to be coextensive with generally accepted standards of care and reversing the judgment on the plaintiff’s denial of benefits claim; and (4) remanding to the district court to answer the threshold question of whether the fiduciary duty claim was subject to the plans’ administrative exhaustion requirement. The new ruling allows for the possibility that some plaintiff claims will be reprocessed and a possibility that the district court to issue revised class benefits.
With this new ruling in Wit v. United Behavioral Health, there is renewed optimism in what lies ahead for ensuring Americans’ rights to mental health and addiction coverage in alignment with clinical standards. We await the district court’s decision.
The Court of Appeals for the Ninth Circuit (3-judge panel) released a third ruling in which they reconsidered portions of the District Court findings, vacating its January 2023 ruling, potentially opening the door for some plaintiff claims to be reprocessed. The panel granted a panel rehearing and instructed the district court to resolve a question over the plan’s administrative exhaustion requirement, a positive movement forward from January’s ruling.
15 states plus Washington, D.C., the U.S. Department of Labor, and advocates including The Kennedy Forum submitted amici briefs supporting a rehearing of the case by the Ninth Circuit Court of Appeals.
The Court of Appeals for the Ninth Circuit (3-judge panel) released a new ruling in which they affirmed in part, reversed in part, and remanded for further proceedings. The panel determined that even though UBH violated both its fiduciary duty by creating medical necessity criteria that put its self-interest ahead of plan members’ and the laws of four states – more than 50,000 individuals denied mental health or addiction coverage have no right to reprocessing of their claims.
Plantiff’s response to UBH’s June 2022 reply brief
United Behavioral Health’s reply brief (UBH’s response to the appeal).
Appeal to en banc review (full panel of judges review instead of a small panel).
The Court of Appeals for the Ninth Circuit (3-judge panel) reversed the District Court’s ruling. In a paragraph-long decision, the three judge panel determined that it’s “not unreasonable” for health insurers’ coverage determinations to be inconsistent with generally accepted standards of mental health and addiction care.
Plaintiffs responded to the UBH appeal with their own court filing, contesting UBH’s legal bases on appeal. Additionally, The Kennedy Forum and 25 other advocacy organizations filed an amicus brief —alongside political leaders like California Attorney General Rob Bonta and the U.S. Department of Labor, which filed its own amicus brief—in support of the lower court’s ruling.
UBH attorneys appealed the District Court ruling.
Judge Spero issued a ruling related to the remedy phase of this case. The ruling in the remedy phase of Wit v. UBH required the company to reprocess 67,000 claims using medical necessity criteria established by mental health and addiction clinical specialty associations.
Judge Joseph Spero of the United States District Court for the Northern District of California issued the findings of fact and conclusions of law in Wit v. United Behavioral Health (UBH), a class action brought against the country’s largest behavioral health insurer. The 2019 decision ruled that UBH’s care utilization review guidelines — named the “Level Of Care Guidelines” — were inconsistent with the generally accepted standards of care utilized by the medical community. Rather than following standards that require treating chronic and co-existing treatments together, the court found that UBH followed internally-developed guidelines that limited coverage to solely “acute” episodes or crises.
Key Legal Documents
- 9th Circuit Court of Appeals Three-Judge Panel Decision (August 2023)
- Amicus Briefs: Ninth Circuit Court of Appeals (March 2023)
- 9th Circuit Court of Appeals Three-Judge Panel Decision (March 2022)
- Amicus Briefs: Ninth Circuit Court of Appeals (May 2021)
- California (Attorney General Bonta)
- Department of Labor
- American Psychiatric Association, American Medical Association et. al
- National Health Law Program, Kennedy Forum, et al (25+ partners)
- Amicus Briefs: Ninth Circuit Court of Appeals, En Banc Review (May 2022)
- American Psychiatric Association, American Medical Association
- California (Attorney General Bonta)
- Rhode Island, Connecticut, and Illinois
- National Health Law Program, Kennedy Forum, et al
- National Association for Behavioral Healthcare/American Psychological Association/American Hospital Association
- United Behavioral Health’s reply brief/appeal response (June 2022)
- Plantiff’s response to UBH’s June 2022 reply brief (June 2022)
- District Court of Northern California Decision
For media inquires, contact Meredith Elkins at email@example.com.
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