Denied Mental Health Claims 

Mental Health Parity Law Violations in San Francisco: How to Spot and Fight Them

Mental health care is a critical component of overall well-being, yet insurance companies often fail to provide equal coverage for mental health and substance use disorder treatments compared to physical health conditions. In San Francisco, as in the rest of California and the United States, mental health parity laws require insurers to provide equitable coverage. Nonetheless, violations of these laws are prevalent, leaving policyholders confused about how to obtain necessary care. At DL Law Group, we are dedicated to helping San Francisco residents identify violations of mental health parity laws and ensuring they receive the coverage they are entitled to. Our lawyers have 80 years of combined experience and are prepared to advocate for your rights and hold insurance companies accountable. 

Understanding Mental Health Parity Laws 

Mental health parity laws, like the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and California’s Mental Health Parity Act, require insurers to provide comparable coverage for treatment of mental health and substance use disorders commensurate with the coverage for treatment of physical health conditions to both employer plans covered by the Employee Retirement Income Security Act (ERISA) and individual plans that are governed by state law. 

Key requirements of mental health parity laws include:

• Equal Coverage Limits: Insurers cannot impose stricter limits on mental health or substance use disorder treatments (e.g., number of visits, days of coverage, or dollar amounts) than those applied to medical or surgical treatments. 
• Comparable Cost-Sharing: Copayments, deductibles, and out-of-pocket expenses for mental health care must be equivalent to those for physical health care. 
• No Restrictive Pre-Authorizations: Insurers cannot require more burdensome pre-authorization or medical necessity reviews for mental health treatments than for other medical treatments. 
• Access to Providers: Insurers must provide reasonable access to in-network mental health providers, comparable to access for physical health providers. 

Despite these protections, insurance companies often violate parity laws, denying or limiting coverage in ways that disproportionately affect mental health care. 

How to Spot Mental Health Parity Law Violations 

Insurance companies may engage in practices that subtly or overtly violate mental health parity laws. Here are some red flags to watch for in San Francisco: 

Unequal Treatment Limits: 

• Your insurer limits the number of therapy sessions or inpatient days for mental health treatment, but allows unlimited visits for physical health conditions. 
• Example: Approving only 10 therapy sessions per year for depression, but covering unlimited physical therapy for a back injury. 

Higher Cost-Sharing: 

• You face higher copays, deductibles, or coinsurance for mental health services compared to medical services. 
• Example: A $50 copay for a psychiatrist visit, but only a $20 copay for a primary care visit.

Stringent Pre-Authorization Requirements: 

• Your insurer requires pre-approval for every mental health visit or treatment, but not for comparable physical health treatments. 
• Example: Needing prior authorization for outpatient therapy but not for outpatient surgery follow-ups. 

Limited Provider Networks: 

• The insurer’s in-network mental health providers are scarce, forcing you to go out-of-network and pay higher costs, while in-network physical health providers are readily available. 
• Example: A long wait time to see an in-network therapist, but immediate access to in-network physicians. 

Denials Based on “Medical Necessity”: 

• Your insurer denies mental health claims, claiming the treatment is not medically necessary, while approving similar physical health treatments without scrutiny. 
• Example: Denying residential treatment for substance use disorder but approving extended hospital stays for surgery recovery. 

Exclusion of Specific Treatments: 

• The insurer excludes specific mental health or substance use disorder treatments (e.g., intensive outpatient programs or residential treatment) while covering equivalent physical health treatments. 
• Example: Covering inpatient rehabilitation for physical injuries but denying coverage for inpatient mental health care. 

If you detect any of these issues, you may be experiencing violations of the mental health parity law. Making a record of these discrepancies is crucial to making your case against the insurer. 

How to Fight Mental Health Parity Violations 

Challenging mental health parity violations requires a strategic approach. Here’s how you can take action, with support from DL Law Group: 

Document Everything: 

• Keep detailed records of all interactions with your insurer, including claim submissions, denials, and communications (dates, times, and names of representatives). 
• Note any differences in how mental health claims are handled compared to physical health claims, including costs, approvals, or provider access. 
• Collect medical records, treatment plans, and provider statements to support the necessity of your mental health care. 

Review Your Insurance Policy: 

• Read the policy to understand the coverage of mental health and substance use disorder treatment. Compare the language of your specific plan with the coverage for physical health issues. 
• If you cannot understand the policy language or if what you find seems discriminatory, consider consulting with an experienced attorney to determine if there is a basis for a potential violation. 

File an Appeal:  

• If your mental health claim is denied or limited, file an appeal with your insurer. California law requires insurers to provide clear instructions for the appeals process. 
• Provide documentation, including medical records, correspondence from providers, and evidence of disparate treatment. 

Contact Regulatory Agencies:  

• In San Francisco, you can file a complaint with the California Department of Managed Health Care (DMHC) for HMOs and certain PPOs, or the California Department of Insurance for other plans. These agencies can investigate parity violations. 
• If ERISA governs the plan, you may also want to contact the U.S. Department of Labor for potential assistance. 

Seek Legal Assistance:  

• Mental health parity violations can be complex, particularly when navigating both state and federal laws, such as ERISA and the MHPAEA. An experienced attorney can help you build a strong case and pursue legal action if necessary. 
• DL Law Group has a proven track record of challenging insurers, including securing landmark victories in cases that have set precedents in insurance law. 

Why Choose DL Law Group? 

At DL Law Group, we are passionate about protecting the rights of San Francisco policyholders facing mental health parity violations. Our boutique law firm prides itself on providing individualized, hands-on representation that guarantees your case is handled correctly and thoroughly. Here are reasons for you to have confidence in us: 

• Decades of Expertise: With over 80 years of combined experience, our attorneys are authorities in insurance law, including mental health parity and ERISA litigation. 
• Proven Results: We’ve recovered millions for clients, including $300,000 in a mental health care denial case, demonstrating our commitment to justice. 
• Fierce Advocacy: We bring fierce compassion to every case, treating you as a person, not a case number, and fighting relentlessly for your rights. 
• Free Consultations: We offer free case evaluations with no fees unless we win your case. 

Contact Us Today 

If you think that your insurance company is violating the mental health parity laws in San Francisco, do not let them deny the care that you deserve. Our experienced attorneys will review your case, identify violations, and fight to secure the benefits you’re entitled to. We will evaluate the situation and, if we find any violations or breaches, ensure that the insurance company provides the benefits you are entitled to receive. Please do not hesitate to contact us by phone or visit our San Francisco office to schedule a consultation. You will have the right to be heard and receive benefits.