Miscellaneous

Medically Necessary

By Anne Skove, Esq.

How does a disease become a disease?

Sometimes inclusion in the DSM (whatever version we're up to now), or some other sign of acceptance by the medical community, will suffice.

But patients with commonly-known disorders such as anorexia and bulimia are being denied insurance coverage. Insurers say benefits are for "medically necessary" claims.

It is not clear (at least to insurance companies) whether eating disorders are biologically-based mental illnesses, which would require a higher level of coverage than those for mere (and we say that, you know, while rolling our eyes) mental illnesses.

"Hey!" you're thinking, "what about parity laws?" Good thinking! Parity laws require insurers to cover mental health and physical health equally. Thus, caps on the number of outpatient visits or other limits on mental health treatment (which, arguably, can cost more in lost wages, family breakdown, unemployment, homelessness, etc. in the long run) can't exist unless there are similar insurance limits on coverage for physical health.

BUT...state parity laws are pre-empted by ERISA, says the court.

Patients are seeking class status in order to proceed with a class action suit against Horizon Blue Cross of New Jersey.

See Class Action Seeking Insurance for Eating Disorders, Henry Gottlieb, New Jersey Law Journal (February 29, 2008). See also the New Jersey Courts' Mass Tort Information Center.

By the way, this is National Eating Disorders Awareness Week. The National Eating Disorders Association offers How to Afford Appropriate Treatment for an Eating Disorder: A Guide for Patients & Their Families.

Full post as published by court-o-rama.org on February 29, 2008 (boomark / email).