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The question arises whether mental health befits and substance abuse disorder benefits available under ERISA. The answer lies in how the individual long-term disability plan is written.
In the case of Wit v. United Behavioral Health (No. 14-CV-02346 [and the related case No. 14-CV-05337-JCS]), the U.S. District Court in the Northern District of California ruled that if a company has a plan that allows for these type of benefits, the plan administrator may not abuse its discretion by adopting guidelines for the plan that:
Allows a conflict of interest in an attempt to keep expenses down and increase revenues into the plan;
Allows financial considerations to influence the development of the guidelines and not shielding the individuals who develop these guidelines;
Refuses to adopt generally accepted clinical guidelines despite the recommendations from clinicians to do so and against some states’ requirements stipulating standards of care.
The Court notes that a key issue raised in the case is the coverage for behavioral and substance use disorders as chronic, rather than acute conditions. The Plaintiffs argued that this distinction allowed for a termination of benefits once the conditions subsided and did not allow for long-term services needed to stabilize the condition.