An NBC news investigation has found that health plans improperly denied coverage of mental health services in 48 percent of all cases. The California Department of Managed Health Care ("DMHC") conducts independent medical reviews of insurance health claims denied based on lack of medical necessity. The DMHC reviews have resulted in overturning more mental health denials than any other type of medical condition or diagnosis.
The parents in the NBC news article discovered the hard truth that insurance companies make benefit determinations even though its medical reviewers will never see the patient. This is particularly troublesome for claims for treatment of mental illness which necessarily requires in-person clinical evaluation and assessment to determine diagnosis and proper treatment.
If your health claim is denied, you have options. An administrative appeal or a request for an independent medical review to a state agency such as California's DMHC may reverse the insurance company's decision to deny benefits. However, the decision to request an independent medical review may also affect the opportunity to subsequently file a lawsuit if the review is not favorable.