Residential Treatment Center Denied Claims

Why Insurers Deny RTC Claims in San Francisco And How to Appeal

Choosing behavioral healthcare or substance use disorder treatment in a Residential Treatment Center (RTC) often proves to be a crucial factor in getting individuals intensive mental health or substance use disorder treatment. In San Francisco, insurance companies regularly deny RTC claims, making it challenging for their policyholders to access the necessary care. Knowing why insurers deny RTC claims and how to appeal the denials can provide benefits to which you are entitled. At DL Law Group, our attorneys routinely assist individuals in San Francisco in challenging wrongful denials and guide them through the appeals process, leveraging over 80 combined years of experience in insurance litigation. Below, we discuss some of the most frequent reasons RTC claims are denied, the process of taking an appeal, and how DL Law Group can help you fight back. 

Why Insurers Deny RTC Claims 

While insurers in San Francisco and California fully offer claims for RTC, they often deny these claims because they prioritize profit over the needs of policyholders. Reasons include: 

1. Medical Necessity Disputes: 
2. Insurers claim RTC treatment is not "medically necessary," and an "out-patient therapist" is fine, for example.   
3. Example: restricting coverage for a residential program for major depression by arguing that the members' phone calls once a week are fine therapy. 
4. Policy Exclusions: 
5. Some policies carry specific exclusions for RTC (or certain types of mental health or substance abuse treatments).   
6. Example: denying residential substance abuse treatment for an exclusion and allowing coverage of an inpatient medical/hospital level of care. 
7. Lack of Pre-Authorization: 
8. Insurers often require pre-authorization for admissions to RTCs. Failure to obtain this approval can result in a denial, even if the treatment is deemed necessary. 
9. Example: Denying a claim because the policyholder did not secure prior approval, despite an urgent need. 
10. Mental Health Parity Violations: 
11. Insurers may impose stricter requirements for RTC claims than for comparable medical treatments, violating federal and California mental health parity laws (e.g., the Mental Health Parity and Addiction Equity Act and California’s Mental Health Parity Act). 
12. Example: Requiring extensive documentation for RTC admission but not for surgical hospitalization. 
13. Insufficient Documentation: 
14. Claims may be denied if the policyholder or provider fails to submit comprehensive medical records, treatment plans, or evidence supporting the need for RTC care. 
15. Example: Denying a claim due to missing physician notes or incomplete functional assessments. 
16. In-Network Provider Limitations: 
17. Insurers may claim that the chosen RTC is out-of-network, resulting in partial or complete denials, even when in-network options are unavailable or inadequate. 
18. Example: Denying coverage for an out-of-network RTC due to a lack of in-network facilities in San Francisco. 
19. Bad Faith Practices: 
20. Some insurers engage in bad faith tactics, such as delaying claims, requesting excessive documentation, or misinterpreting policy terms to avoid paying for care related to RTC. 
21. Example: Repeatedly requesting additional records to delay approval, causing financial strain for the policyholder. 

These decisions can be heartbreaking, particularly when RTC treatment is vital for success. However, policyholders have the right to appeal these denials, and DL Law Group can assist them in navigating this complex process. 

How to Appeal an RTC Claim Denial 

Appealing a denied RTC claim requires a strategic and thorough approach. Here are the key steps to take: 

Review the Denial Letter: 

• Carefully read the insurer’s denial letter to understand the specific reason(s) for the denial (e.g., medical necessity, policy exclusion, or lack of pre-authorization). 
• Note any deadlines for filing an appeal, typically 180 days for ERISA-governed plans or as specified by California regulations. 

Gather Supporting Documentation: 

• Collect comprehensive medical records, including diagnoses, treatment plans, physician notes, and functional assessments that demonstrate the necessity of RTC care. 
• Obtain letters from treating providers (e.g., psychiatrists, therapists) explaining why RTC treatment is essential. 
• Document how the denial impacts your health or recovery, such as worsening symptoms or inability to function. 

Understand Your Policy: 

• Take a careful look through your insurance policy to determine the coverage facts for RTC care and compare them to the coverage facts for medical treatments, so you can assess whether any discrimination occurs (such as in relation to the level of care). 
• Review exclusions for services or procedures, as well as any pre-authorization requirements. 

File the Appeal: 

• Write a written appeal to your insurer, according to their specific appeals procedures. Include all the necessary supporting documents and explain why you believe that it is unjustified to deny your medical coverage. For ERISA plans, you should request a whole and fair review process in accordance with applicable federal regulations.   
• For ERISA plans, request a full and fair review in accordance with federal regulations. For non-ERISA plans, adhere to California’s appeal process, which typically requires a response within 30 days for standard appeals or 72 hours for urgent appeals. 

Seek External Review: 

• If the internal appeal is denied, you can request an independent external review through the California Department of Managed Health Care (DMHC) for HMOs and certain PPOs, or the California Department of Insurance for other plans. 
• For ERISA plans, you may also contact the U.S. Department of Labor for assistance. 

Consult an Attorney: 

• Insurance appeals, particularly for RTC claims, often involve complex legal issues, including ERISA regulations, mental health parity laws, and allegations of bad faith practices. An experienced attorney can strengthen your appeal and pursue litigation if necessary. 

How DL Law Group Can Help 

Dealing with an RTC claim denial can be intimidating, particularly when you’re already grappling with mental health or substance abuse issues. DL Law Group, based in San Francisco, takes a unique approach to supporting policyholders throughout the appeals process. Here’s why you should call us: 

• Specialized Expertise: Our attorneys possess over 80 years of combined experience in insurance law, encompassing ERISA, mental health parity, and bad faith litigation. We have taken on some of the largest insurers and achieved recoveries ranging from thousands to over $425,000 in a residential treatment denial case. 
• Personalized Representation: As a boutique firm, we provide personalized service, ensuring your case receives the attention you expect. We get to know what makes you unique and refashion our practice to suit your needs. 
• Proven Track Record: Our attorneys, including David M. Lilienstein and Alice J. Wolfson, have made legal history with seminal cases resulting in verdicts worth millions, while establishing new law in the field of insurance law. 
• Case Evaluation: We start with you. We review the denial letter, the policy, and the medical records to help identify the basis for the appeal. For example, a parity violation, or bad faith. 
• Documentation Preparation: We assist in gathering and organizing robust evidence, including medical records and provider letters, to strengthen your appeal. 
• Negotiation and Litigation: We negotiate with insurers to secure approvals and, if necessary, litigate to hold them accountable for wrongful denials. 
• Regulatory Complaints: We assist in filing complaints with the California Department of Insurance, the U.S. Department of Labor, or other relevant agencies to enforce your rights. 
• Fierce Advocacy: We approach every case with fierce compassion, treating you as a person, not a case number. We understand the stakes of RTC care and fight relentlessly to secure the benefits you need for recovery. 
• Free Consultations: We offer free case evaluations with no fees unless we win your case, making it risk-free to seek our help. 

Why You Need to Contact DL Law Group 

RTC claim denials can have serious consequences, delaying or preventing access to life-changing treatment. Insurance companies often rely on complex policy language, regulatory loopholes, or bad faith tactics to deny claims, counting on policyholders to give up. Without experienced legal assistance, navigating the appeals process can be time-consuming and intimidating. This is especially the case when dealing with ERISA-related plans or violations of mental health parity. The DL Law Group levels the playing field. Based in San Francisco, our insurance attorneys possess the experience, resources, and courtroom expertise to advocate for you against even the most powerful insurance companies. We have recovered millions of dollars for policyholders after wrongful denials and are nationally recognized leaders in insurance litigation. When you contact us, you will be assigned a partner for your case who will thoroughly analyze it to identify any violations of state or federal law. Construct a compelling appeal with competent evidence and legal arguments. 

• Analyze your case to uncover violations of state or federal laws. 
• Build a compelling appeal with robust evidence and legal arguments. 
• Advocate for your rights either in negotiations or in court to ensure you receive the RTC medical coverage you deserve!   

Contact Us Today 

If you are in San Francisco, and your RTC claim has been denied, don't let the insurance company deprive you of the medical care you need! Contact DL Law Group for a free consultation today. We are experienced attorneys who will review your case, guide you through the appeals process, and advocate for the benefits you deserve. Call us today or visit our San Francisco office to schedule a consultation at your convenience.