Luckily, federal law—specifically the Employee Retirement Income Security Act of 1974 (ERISA) and the Mental Health Parity and Addiction Equity Act (MHPAEA)—has got your back. These laws require insurance plans to treat mental health and substance use disorder benefits the same as medical and surgical care.
At Reynolds& ERISA Law Clinic, we represent individuals when insurers fail to follow these rules. This post explains how mental health coverage works under ERISA, what “mental health parity” really means and what to do if your mental health claim is denied.
What is Mental Health Parity
The Mental Health Parity and Addiction Equity Act (MHPAEA)—which runs alongside ERISA—prohibits group health plans from imposing more stringent limits on mental health or substance use disorder benefits than they do on medical or surgical benefits.
In other words, if your plan covers hospital stays, medications or outpatient visits for physical illnesses, it must cover the same for mental health conditions.
Parity applies to several areas, including:
- Financial requirements: Copays, deductibles and coinsurance for mental health care can’t be higher than for comparable medical care.
- Treatment limitations: The number of therapy visits or inpatient days can’t be capped more strictly than physical health services.
- Medical management: Plans can’t make it harder to get preauthorization for therapy or require extra proof of “medical necessity” for mental health care.
Example: If your plan allows 20 visits per year for physical therapy but only 10 visits for counseling, that’s likely a parity violation.
How ERISA Helps Employees and Plan Participants
ERISA covers most employer-sponsored health plans, including those that offer mental health coverage. It sets national standards for how claims are handled and gives participants the right to appeal denials and if necessary, sue in federal court.
Under ERISA, plan administrators must:
- Disclose mental health benefits and exclusions clearly.
- Explain denial decisions in writing, including the specific reason for the denial and the plan rules used to make that decision.
- Offer an internal appeal process within 180 days.
- Act in your best interest as fiduciaries, fairly and in compliance with federal law.
When plans don’t follow these rules—or apply mental health coverage more restrictively than physical health coverage—they may be violating both ERISA and the parity laws.
Why Mental Health Claims Get Denied
Despite federal protections, insurers deny mental health claims for reasons that don’t hold up under scrutiny. Here are common examples:
- “Not medically necessary” – The insurer claims the treatment isn’t necessary, even when prescribed by a qualified provider.
- “Experimental or unproven” – Certain therapies, like intensive outpatient programs, are wrongly categorized this way.
- Coverage limits or visit caps – The plan limits therapy sessions or inpatient stays more strictly than physical health benefits.
- Administrative technicalities – Missing forms, coding errors or late submissions can trigger denials, even when the care itself is covered.
Tip: Always request a copy of the plan’s medical necessity criteria and compare it to what’s required for similar medical conditions. Parity laws prohibit applying tougher standards to mental health care.
What to Do if Your Mental Health Claim Is Denied
- Read the Denial Letter
ERISA requires that denial notices include:
- The reason for denial
- The specific plan provision involved
- What information is needed to perfect your claim
- How to file an appeal and by what deadline
Mark the 180-day appeal deadline immediately—missing it can forfeit your rights.
- Get Key Documents
You’re entitled to copies of:
- The Summary Plan Description (SPD)
- Any internal guidelines used to make the decision
- The plan’s medical necessity criteria for mental health benefits
- Gather Supporting Evidence
Include:
- Copies of medical records from all providers
- Detailed letters from your therapist, psychiatrist or physician
- Any other information showing medical necessity
- File a Written Appeal
Submit a clear, organized appeal that addresses the reasons for denial. Point out any parity violations or inconsistencies in how the plan applies its rules.
5.Get Legal Help
ERISA appeals are complicated and once your internal appeal is denied, courts may only review the “administrative record” of information already submitted. Working with an attorney early ensures your appeal record is complete and strong enough for possible litigation.
How Reynolds& ERISA Law Clinic Handles Mental Health Benefit Disputes
Mental health claims are denied not because care is unnecessary but because insurers misapply the law or use outdated medical necessity criteria. Our attorneys at Reynolds& ERISA Law Clinic have years of experience finding these violations and holding insurers accountable.
We help clients by:
- Reviewing plan documents for parity and ERISA compliance
- Preparing and submitting detailed appeal packages
- Advocating for fair access to therapy, counseling and psychiatric care
Why Mental Health Parity Matters
Mental health conditions like depression, anxiety and trauma-related disorders are just as real and disabling as physical illnesses. Congress passed parity laws to ensure fair and equal access to treatment—and ERISA gives employees the right to enforce those protections.
When insurers deny legitimate mental health claims, they’re not just violating the law—they’re denying individuals the care they need to get better.
At Reynolds& ERISA Law Clinic, we believe no one should have to fight alone to get the mental health care their benefits promise.
If your mental health claim has been denied or restricted, schedule a consultation with Reynolds& ERISA Law Clinic today. Our attorneys can help you navigate the ERISA appeals process, assert your parity rights and get the coverage you deserve.
Equal Access to Mental Health Care
Knowing your ERISA and Mental Health Parity rights is the first step to protecting your access to care. If your employer-sponsored plan treats mental health differently than physical health, that’s not fair—it’s illegal.
With legal guidance, you can hold insurers accountable and make sure your mental health benefits are honored as the law requires.
Reynolds& ERISA Law Clinic can help you do just that.
source https://www.reynoldsand.com/erisa-and-mental-health-claims/
No comments:
Post a Comment