Denied Mental Health Claims 

Your Rights When Insurance Denies Teen or Youth Mental Health Care?

When an insurance company denies mental health care coverage for a teen or youth in San Francisco, it can be a devastating blow for families seeking critical treatment for their loved ones. Mental health issues among adolescents, such as depression, anxiety, eating disorders, or substance use disorders, often require timely and intensive interventions. However, insurance companies usually deny claims for various reasons, including "medical necessity" or policy exclusions. It is essential to understand your rights as a policyholder and how to challenge these denials to ensure your teen receives the care they are entitled to. At DL Law Group, with over 80 years of combined experience in insurance litigation, we are dedicated to helping San Francisco families challenge wrongful denials and access the mental health benefits to which they’re entitled. Below, we outline your rights and the steps to take when an insurer denies teen or youth mental health care. 

Your Rights Under Mental Health Parity Laws 

In San Francisco, both California and federal laws protect your right to equitable mental health coverage for teens and youth. Key protections include: 

• Federal Mental Health Parity and Addiction Equity Act (MHPAEA): This law requires insurers to provide mental health and substance use disorder coverage that is comparable to medical or surgical coverage. This includes equal treatment limits, cost-sharing (e.g., copays, deductibles), and access to providers for youth mental health care. 
• The California Mental Health Parity Act requires insurers to cover medically necessary mental health and substance use disorder treatments for all ages, including teenagers, on the same basis as physical health treatments. This applies to conditions like depression, anxiety, bipolar disorder, and eating disorders. 
• ERISA Protections: If your insurance plan is employer-sponsored and governed by the Employee Retirement Income Security Act (ERISA), you have additional federal protections, including the right to a “full and fair review” of denied claims and strict timelines for insurer responses (e.g., 30 days for standard appeals, 72 hours for urgent appeals). 
• Right to Appeal: You have the right to appeal any denial of mental health care coverage, whether for outpatient therapy, residential treatment, or other services. Insurers must provide clear appeal instructions and adhere to state and federal timelines. 
• Protection Against Bad Faith Practices: Insurers are required to act in good faith when handling claims. Delaying, denying, or underpaying claims without valid reasons may constitute bad faith, giving you grounds for legal action. 

These laws ensure that teens and youth in San Francisco have access to necessary mental health care. Still, insurers often violate these protections by denying or limiting coverage. 

Common Reasons Insurers Deny Teen or Youth Mental Health Care 

Insurance companies have a variety of methods for denying mental health claims for teens and youth, often using complicated policy language and regulatory loopholes to do so. Some reasons for denial are: 

Medical Necessity Disputes: 

• Insurers may claim that the requested treatment (e.g., residential treatment, intensive outpatient programs) is not medically necessary, asserting that less intensive care is sufficient. 
• Example: Denying residential treatment for a teen with severe anorexia, claiming outpatient therapy is adequate. 

Policy Exclusions: 

• Some policies exclude specific treatments, such as residential treatment centers (RTCs) or experimental therapies, even when medically necessary. 
• Example: Excluding coverage for a teen’s inpatient substance use treatment while covering inpatient medical care. 

Lack of Preauthorization: 

• Insurers may require preauthorization for specific treatments and may refuse to pay a claim when this step is not completed, even though the treatment is urgent. 
• Example: Denying coverage for emergency psychiatric care because preauthorization was not obtained. 

Mental Health Parity Violations: 

• Insurers may apply stricter standards for mental health care than physical health care, in violation of parity laws. 
• For example, requiring pre-approval for all therapy visits, but not for physical health visits. 

Insufficient Documentation: 

• An insurer may deny a claim because it believes the medical records, provider documentation, or functional assessments do not adequately document the client's needs for the requested service. 
• For example, denying a claim for a teen who had suicidal ideation because the therapist's notes did not provide enough detail about the teen's prior suicidal ideation. 

Out-of-Network Restrictions: 

• Insurers may deny coverage for out-of-network providers, even if in-network mental health providers are unavailable or unsuitable for the individual's needs. 
• Example: Denying coverage for an out-of-network therapist due to limited in-network options in San Francisco. 

Bad Faith Tactics: 

• Some insurers delay claims, request excessive documentation, or misinterpret policy terms to avoid paying for costly treatments, such as RTCs or inpatient care. 
• Example: Repeatedly requesting additional records to delay approval of a teen’s residential treatment. 

These denials can jeopardize a teen’s health and recovery. Still, you have the right to challenge them through appeals and legal action. 

Steps to Take When a Claim Is Denied 

If your teen’s mental health care claim is denied, you can take the following steps to fight back: 

Review the Denial Letter: 

• Carefully read the insurer’s denial letter to identify the specific reason(s) for the denial (e.g., medical necessity, lack of preauthorization, or policy exclusion). 
• Be aware of the deadline to appeal, which is typically 180 days for ERISA plans or as specified by the insurer. 

Gather Supporting Documentation: 

• Collect complete medical records that contain diagnosis, treatment plans, and letters from providers indicating the teen's condition and need for the requested care. 
• Include evidence of functional impairment, such as school absences, declining grades, or safety risks (e.g., self-harm or suicidal ideation). 
• Document any disparities in how mental health claims are handled compared to physical health claims, as this may indicate a parity violation. 

Understand Your Policy: 

• Examine your health insurance policy to see if mental health services are covered and how they may be different from your coverage for physical health services. 
• Look for exclusions, preauthorizations, and/or network constraints, among other things. 

File an Appeal: 

• Submit a written appeal to the insurer, following their guidelines and procedures. Include all supporting documentation and a clear explanation of why the denial is unjustified. 
• For urgent cases (e.g., a teen at risk of self-harm), request an expedited appeal, which must be resolved within 72 hours under California and ERISA regulations. 
• Highlight any potential violations of mental health parity laws or bad faith practices. 

Seek External Review: 

• If the internal appeal is denied, 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: 

• Navigating denials for teen mental health care can be complex, especially when dealing with ERISA, parity laws, or bad faith practices. An experienced attorney can strengthen your appeal and pursue litigation if necessary. 

Why You Need to Contact DL Law Group 

Insurance companies often hope that families just give up after a denial, especially with teen mental health care. With all the emotional and financial pain of being denied, you might understandably be inclined to walk away. Denials can be filled with complicated issues of law on top of mental health-related problems. For example, ERISA regulations can be complicated and intertwined with mental health parity and bad faith. Simply put, a family new to mental health care claims should hire experienced counsel to help navigate the denial and be able to properly evaluate and articulate the complex legal issues that are likely embedded in the denial. If you do not use the appropriate counsel, you could suffer substantial delays or lose valuable treatment for your teen altogether. DL Law Group levels the playing field. Our attorneys are based in San Francisco and bring years of experience, having recovered millions of dollars in settlements and final judgments for clients throughout California. We take a client-centered approach to every client's case. We understand the urgency to secure the needed mental health care for a teen or youth, and we will fight for your family’s rights. 

Contact Us Today 

Don't let the insurance company hinder your teen's recovery, especially if their mental health care coverage has been denied in San Francisco. You can call DL Law Group for a free consultation. Our experienced attorneys will evaluate your claim, guide you through the appeal process, and fight for the benefits your teen deserves. Contact us to schedule your consultation or visit our San Francisco office. We will make it easy and convenient for you to talk to an attorney.