Patients with mental health concerns often require health insurance to cover medically necessary services.

Insurance companies should prioritize patient needs when determining whether insurance covers services.

Patients and clinicians may raise questions when insurance coverage is denied.

Patients and clinicians should understand their rights to appeal insurance denial decisions.

In a series of court processes dating back to 2014, judges have examined how health insurance companies should balance their responsibilities to people seeking mental health care against their own financial interests (Wit v. United Behavioral Health, 2023, 2026). Insurance companies have financial incentives to limit reimbursements for services and maximize profits for shareholders. However, when administering certain employer-sponsored health plans,1 insurers have fiduciary duties requiring them to prioritize the interests of plan participants and beneficiaries over their own financial interests (cf., Employee Retirement Income Security Act, 1974). These obligations are similar, although not identical to the fiduciary responsibilities of psychologists and other mental health professionals (MHPs) to their clients (ACA, 2014; APA, 2017; NASW, 2021).

Ordinarily, access to mental health treatment should be based on patient needs and wishes (Olejarczyk & Young, 2024). Health insurance is intended to facilitate access to covered services, including psychotherapy, inpatient care, outpatient treatment, and other mental health and addictions services. But what happens when an insurer's financial interests conflict with its responsibilities to the people it insures?

What Are Generally Accepted Standards of Care?

Generally accepted standards of care refer to clinical principles and evidence-based treatment guidelines broadly recognized by mental health professionals as appropriate for assessing and treating patients (Wit v. United Behavioral Health, 2023). There is no singular set of standards of care that apply to all contexts of practice or all treatment decisions. Standards may vary for particular mental health concerns, diagnoses, and client situations. Across various types of treatment decisions, however, accepted standards of care should typically:

address underlying conditions rather than simply stabilize immediate crises;

consider co-occurring disorders;

provide treatment at a safe and effective level of care; and

tailor treatment duration to individual needs (Wit v. United Behavioral Health, 2023).

Importantly, clinically appropriate treatment may include services that maintain functioning or prevent........

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