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Landmark lawsuits

Minnesota case on mental health treatment

In 2000 a lawsuit was filed by Minnesota Attorney General Mike Hatch against Blue Cross/Blue Shield of Minnesota (BCBSM) for violating insurance and fraud laws. Hatch alleged that BCBSM denied coverage for children with mental disorders, including eating disorders, and that BCBSM told the parents of these children to place them in foster care to receive free health benefits from the state. More than 80 families provided grievance statements against BCBSM. The case was settled out of court in 2001 with a financial settlement and new policy guidelines adopted by BCBSM. BCBSM agreed to set up an independent panel to review appeals of rejected claims and to put guidelines in place to expedite this process. BCBSM also increased their coverage for patients with eating disorders and placed very short time limits on these appeals. Because BCBSM made so many drastic policy changes to their mental health policy as a result of this lawsuit, this case has been heralded by mental health advocacy groups as a major victory in the fight for mental health benefits parity.

Insurer found to have acted in bad faith

In Wisconsin in 1991, Susan McEvoy sued Group Health Cooperative (GHC) for denying care for her 13-year old anorexic daughter Angela. Angela was admitted to a hospital and treated for six weeks as an inpatient until GHC stopped paying for hospitalization. Even though Angela's coverage had not run out, GHC decided to place Angela in an outpatient treatment program. Angela's primary care physician and the hospital psychiatrist both disagreed with GHC's decision, but she was discharged from hospital care to start the outpatient program anyway. During the next two months of outpatient treatment, her weight dropped from 95 to 74 pounds, and she was eventually readmitted to the hospital. After an eight-day hospitalization, Angela entered an eating disorder program. Her mother filed a "bad faith" claim against GHC for stopping the inpatient care. Bad faith is a legal term that meant, in this case, that although GHC was not in breach of contact, its decision to switch Angela from inpatient to outpatient care was not in her best interest. The court ruled in favor of Angela and her mother. This case set a precedent that a health plan can be held accountable for acting in bad faith.

A case of medical versus mental health benefits

In 1989 Ronald Simons sued Blue Cross and Blue Shield of Greater New York (BCBSGNY) for reimbursement for hospitalization costs for his daughter's 68 days of inpatient anorexia treatment. The health plan benefits stated that it covered 30 days of inpatient care for psychiatric disorders and 120 days of inpatient care for physical disorders, but refused to pay for any hospitalization over 30 days, citing anorexia as a psychiatric disorder. Simons' lawyer argued that because Simons' daughter was hospitalized and treated for malnutrition, which is not a psychiatric disorder, the health plan should pay for all of the hospitalization, not just 30 days. The court ruled in favor of Simons, stating that when physical problems arise from a psychiatric condition, the treatment for those problems should be covered under the medical benefits of the plan. Simons' daughter was admitted to the hospital for malnutrition, a physical complaint, and was treated accordingly. The court stated that although she may have received psychological counseling along with the physical treatment, the primary cause of the hospitalization was physical and the fundamental nature of the treatment was physical. The court made no ruling on whether anorexia was a physical or psychiatric illness.

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Bulimia nervosa is an eating disorder in which a person engages in binge eating (eating a lot of food in a short time) followed by some type of behavior to prevent weight gain from the food that was eaten. This behavior can take two forms: self-induced vomiting, misuse of enemas, laxatives, diet pills (called purging) and excessive exercise, fasting, or diabetic omission of insulin (called non-purging). Some people with bulimia nervosa may also starve themselves for periods of time before binge eating again. Bulimia nervosa has important mental, emotional, and physical aspects that require consideration during treatment.

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