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Lawsuits seek
full coverage for eating
disorder treatment
(June
2007 Issue)
By Elinor Nelson
Fed up with insurance companies' limiting hospitalization for eating
disorders to 30 or 35 days when doctors are saying their children
need longer stays for a chance at a cure and cognizant that anorexia
nervosa has the highest mortality rate of any mental illness, families
are starting to sue the insurance companies. Three class action
suits have been filed in Federal District Court in New Jersey, one
against Aetna and two against Horizon Blue Cross Blue Shield of
New Jersey.
The cases turn on the interpretation of "biologically-based mental
illness" (BBMI), for which New Jersey state law mandates more comprehensive
benefits than for non-BBMI's. The law says that a BBMI is caused
by a "biological disorder" of the brain resulting in a "clinically
significant or psychological syndrome or pattern," and includes
a non-exclusive list of covered psychiatric conditions and illnesses.
Anorexia is not on the list and Aetna and Horizon interpret the
law to exclude anorexia.
Daniel Emmer, Horizon's manager of public relations, states that
"Horizon's position is that the legislature, and not the court,
should decide what benefits the statute mandates." Cynthia Michener
of Aetna states in an email that Aetna covers treatments related
to eating disorders subject to any limits in the member's benefits
plan. "Some plan designs may limit certain types of coverage…to
create affordable health benefit plans that employers can purchase
to provide the maximum amount of coverage for as many employees
as possible. "
The plaintiffs' attorney in one of the cases, David Mazie of Mazie,
Slater, Katz & Freeman, LLC of Roseland, N.J., asserts that eating
disorders are BBMI's, and "in fact, we have clients who are sisters
- one aspect, I think, that it is biologically based." His complaint
quotes Scott Crow, M.D., University of Minnesota professor of psychiatry
and immediate past president of the Academy of Eating Disorders
as "somewhat surprised that such antiquated notions persist in the
face of strong and consistent evidence for the biological basis
of these disorders."
Wade Berrettini, M.D., Ph.D., professor of psychiatry and director
of the University of Pennsylvania's Center for Neurobiology and
Behavior is quoted in the complaint as stating, "Dozens of researchers
across the world are making an extraordinary effort to find genes
which predispose individuals to anorexia nervosa… because identical
and fraternal twins studies…prove that genes influence anorexia
nervosa risk."
The National Association for Anorexia Nervosa and Associated Disorders
(ANAD) emphatically agrees, and its Web site (www.anad.org) excerpts
a letter from Thomas R. Insel, M.D., director of the National Institute
of Mental Health, stating, "Research tells us that anorexia nervosa
is a brain disease with severe metabolic effects on the entire body.
While the symptoms are behavioral, this illness has a biological
core with genetic components, changes in brain activity and neural
pathways that are currently being studied."
Darcy Gans, ANAD's associate director of media relations, explains
that ANAD gets "many calls from families with children in inpatient
programs, but caps on their inpatient days means that they are discharged
prematurely, long before they're recovered. Some of them are uninsured,
but some of them have insurance, but it's too little too late."
Mary Elsner, J.D., ANAD's director of advocacy and government affairs,
says that while national mental health parity legislation is pending
in Congress, for now, these cases rely on each state's insurance
law. Some states mandate more benefits than others.
ANAD's Web site cites a survey of 109 eating disorder specialists
around the country concluding that 96.7% "believe their patients
with anorexia are put in life threatening situations because of
mandated early discharge."
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