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Legal News
Insurers' Refusal To Cover Eating Disorders Prompts Lawsuits
Psychiatric News
Volume 42 Number 2 page 1-31

Two proposed class-action lawsuits are bolstering efforts to get a tougher mental health insurance parity law in New Jersey. They are also reinforcing a top APA priority—extending mental health parity.

Thirty-nine states have laws to assure that individuals receive the same health insurance coverage for mental illness as they do for physical ones. However, the scope of these parity laws and the true protection they provide vary dramatically.

The law in New Jersey, for example, states that all mental illnesses that are biologically based must be reimbursed comparable to other kinds of medical illnesses. Yet when the daughter of Bart and Dawn Beye of Wayne, N.J., required extensive inpatient treatment for anorexia nervosa, the Beyes' health insurance company, Horizon Blue Cross/Blue Shield of New Jersey, refused to reimburse the Beyes for much of it, according to a report in the July 28, 2006, Newark Star-Ledger. Horizon's rationale in refusing was that anorexia nervosa is not biologically based.

Dawn Beye “then played the insurance game [the insurance company's] way,” she explained in a December 10, 2006, memo sent to Robert Bransfield, M.D., a Red Bank, N.J., psychiatrist and member of APA's Task Force on Parity, and to Psychiatric News. She said she obtained“ documented proof, letters from the top eating-disorder experts in the United States that verify that eating disorders are biologically based.” She filed all the appeals and even fought for an appeal through the New Jersey Department of Banking and Insurance. “I was still denied the coverage that my daughter is entitled to,” she said.

By going public with her battle with the insurer, Beye said, 40 other families contacted her looking for help on how to get insurance coverage from Horizon for their anorexic children. Thus, on November 8, 2006, she filed a proposed class-action lawsuit against Horizon, representing all such families in New Jersey.

Also on that day, according to the November 8, 2006, New York Times, Cliff and Maria DeAnna of Mountainside, N.J., filed a suit against Aetna Inc. They claimed that Aetna refused to pay for the full costs of treating their daughter's anorexia because it was not biologically based. They also sought class-action status for their legal claim because they contended that many other families had been denied coverage by Aetna for the same reason.

Indeed, according to an article in the November 10, 2006, New Jersey Law Journal, as many as several thousand New Jersey residents who have been refused reimbursement by Horizon, Aetna, and other insurers for anorexia treatment are eligible to participate in such class-action lawsuits.

The argument that Horizon and Aetna are using in denying anorexia coverage, Bransfield told Psychiatric News, is that the New Jersey parity law gives examples of only six mental illnesses that are biologically based, and anorexia is not one of them. Yet there is strong evidence that anorexia is biologically based, he stressed. So, “according to the current statute, anorexia should be included,” he said.

Although the outcome of the proposed class-action status for the suits is not yet known, they could be a major boost for the cause of mental health insurance parity, Bransfield believes. “We could set a precedent with these cases, demonstrating that all DSM diagnostic categories are biologically based,” he said.

Even if such a positive outcome does not come to pass, he added, the lawsuits are bolstering efforts to pass a tougher mental health insurance parity law in New Jersey.

In fact, a stronger law, which would require equal health insurance coverage for all DSM diagnoses as well as for alcohol and substance abuse disorders, was considered by the New Jersey Senate on December 4, 2006. After a day of lobbying by patients' rights groups and representatives of organized medicine—including Tim Martin, the lobbyist for the New Jersey Psychiatric Association—on one side, and insurance companies and businesses on the other, the Senate overwhelmingly voted for the bill.

An identical bill passed the New Jersey Assembly Health Committee and is currently pending before the Appropriations Committee, which will have to pass the bill before the full Assembly votes on it, Martin said. ▪

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