“Not medically necessary.”
In short, our insurance company failed us.
Our insurance company failed our teenage son and as a result he paid with his life.
We paid with unimaginable, endless, all-consuming grief.
On January 11, 2015, our 15-year-old son Jake died of suicide. He died because our insurance company considered that his mental health treatment was not necessary from a medical point of view, in direct contradiction with the assessment of his doctors.
No other family should experience the loss we have experienced.
The court decision offers the necessary protection
Together with many advocates of mental health, we rejoiced on February 28, 2019 in response to a remarkable decision on one of the most important cases of health policy of the 21st century, Wit v. United Behavioral Health (UBH).
In the ruling, the judge found that UBH (the nation’s largest insurer) had erred in using its internally developed coverage standards instead of generally accepted clinical standards. We believed that insurance companies would eventually be held accountable for making medical necessity decisions in accordance with accepted clinical standards, rather than refusing coverage based on arbitrary, non-transparent, profit-driven, internally developed criteria.
Now the appellate court has jeopardized our profits. His decision must not remain in force.
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The decision of the trial court in The Wit v. UBH was a huge victory for people seeking mental health treatment – and would force insurers to change their practices for the better. These changes would help Jake.
Outpatient services didn’t help Jake
Jake was hospitalized twice in a month for suicidal thoughts.
During his first hospitalization, he spent five days in hospital before being admitted to an outpatient program, as required by our insurance company. The program was not successful. He was hospitalized again, where he was kept for another five days.
We knew he wasn’t ready to go home, and his doctors agreed. Not only did our insurance company disagree, citing medical necessity, they insisted on returning to the same outpatient program in which it no longer succeeded.
Despite our advocacy and that of his doctors, our insurance company was adamant that he would again have to fail the outpatient program before he could switch to an inpatient program.
We called on them to reconsider, but all they could offer was an appeal. We were in a crisis like Jake, but we decided to file a complaint.
We received a huge package of documents in the mail and had no idea what to do and where to start. There was so much needed data and information that we could not provide. Our son’s life was distilled in a bunch of medical codes we didn’t understand.
Less than three months later, he committed suicide.
Review this decision so that other families are not at risk
The medical necessity criteria used by insurance companies are imbued with stigma and non-compliance, not clinical guidelines. If Jake had heart disease and his doctors believed his heart wasn’t strong enough to go home, they would keep him in the hospital. Why was that different? Because he had a mental illness.
Shortly before his 15th birthday, in October, he was released and by January 11 he was gone.
The Wit v. UBH ruling, which once gave us some hope for change, was inexplicably overturned by three judges at the 9th District Court of Appeal, which includes Arizona. I am not riveted by this alarming and unscrupulous reversal, which will encourage insurers to make decisions according to their own logic and contrary to clinical standards.
The court ruling, as it is now, means that those who need care will not receive it. Jake’s doctors knew he needed hospital care. They knew the severity of his suicide and that the outpatient treatment was not working.
However, the insurance canceled the medical specialists who knew about our son’s serious condition. They did not pay for the necessary treatment, but we did.
We paid the final price.
There is still time for the 9th district judges to reconsider this case. It is urgently needed. If left unchecked, millions of Americans seeking access to treatment may not find it when they need it most.
Denise Shat-Denslow is the CEO and co-founder of The JEM Foundation, which seeks to prevent youth suicides. She and her husband, Ben Denslow, also formed the Arizona Insurance Parity Coalition, which focuses on passing legislation to ensure that health insurance companies cannot differentiate between physical health and mental health. Contact her at [email protected].