US Labor Department Sues UnitedHealth Group Over Claims Denials
August 15, 2023The United States Department of Labor (DOL) has initiated legal proceedings against UnitedHealth Group, citing thousands of instances of denied claims for emergency room (ER) services and urinary drug screenings spanning from 2015.
The lawsuit contends that the basis for rejecting ER claims rested solely on diagnosis codes, a departure from the “prudent layperson” standard mandated by health plan documents. The standard dictates that insurance providers should assess whether an average person, with average medical knowledge, would reasonably believe that their symptoms require immediate medical attention. If a person seeks ER care based on this standard, their insurance should cover the costs, regardless of the final diagnosis.
Additionally, the litigation alleges that UnitedHealth Group’s division should have implemented a medical necessity criterion for urinary drug screening claims. Instead, it purportedly employed a non-standardized approach, leading to the blanket denial of all such claims.
The civil lawsuit has been filed specifically against UMR Inc., a subsidiary of UnitedHealth Group Inc., within the U.S. District Court for the Western District of Wisconsin. UMR, acting as a claims administrator, handles healthcare claims and various services for over 2,100 self-funded plans. The DOL contends that the company’s denial of ER visits and urine drug screens over an extended period did not align with the federal standards mandated for self-insured plans, which are financed by employers. These standards are governed by the Employee Retirement Income Security Act (ERISA).