Legal Cases: Eating Disorders - Page 2

Violation Category: Care rendered at a residential treatment facility was not covered under the terms of plaintiff’s plan.

Short Description: Plaintiff suffers from anorexia nervosa and needed care at an in-network facility. Plaintiff had been receiving intensive outpatient treatment, however her doctors determined that this care was not sufficient. When she arrived at a residential treatment facility she was at 65% of her ideal body weight. Less than a month later, she had to have a feeding tube inserted because her caloric level needed to gain weight was so high. In examining the case, the Court first considers whether the treatment received at Castlewood is covered under the plan. The Plaintiff argues that the treatment is covered because 1) the plan covers residential care, and 2) that her care at Castlewood was care received at a Skilled Nursing Facility (SNF). The Court rejects both arguments due to the clear language of the plan language stating that residential care is not covered and that Castlewood cannot qualify as a SNF. The Court then considers the impact of the California Mental Health Parity Act. In holding that the care must be covered, the Court states that the Mental Health Parity Act requires a plan provide all medically necessary treatment for severe mental illnesses. Further, the Court finds that here, Harlick’s care was medically necessary.

Appeal/Disposition: Appellate court reversed the judgment of the district court.

Violation Category: Plaintiff’s daughter was hospitalized for 15 days and required additional residential treatment. Plaintiff requested pre-authorization, which was denied, and continued appealing the decision. Plan administrators continued to deny the claim based on the fact that residential treatment for anorexia nervosa was not covered by the plan. Plaintiff appealed through both the Plan and to OPM – OPM upheld the Plan’s denial.

Short Description: Plaintiff argued the Plan was acting in violation of FEHBA, and state and federal parity laws. Defendant OPM argued that the Court lacked jurisdiction over the claimed violation of CA Mental Health Parity Law. The Court agrees with this argument in that there is no explicit waiver by Congress allowing OPM to be sued for violations of this Act. Defendant also argued that the Court lacked jurisdiction over the claimed violation of MHPAEA due to sovereign immunity. MHPAEA did not amend FEHBA, meaning that those plans are under no requirement to comply with MHPAEA requirements. Even though OPM voluntarily decided to require plans to follow MHPAEA, the action of an agency does not create an effective waiver. Further, Congress did not consent to allow the government to be sued for violations of MHPAEA.

Appeal/Disposition: The Plaintiff’s motion for summary judgment was denied. The Defendant’s motion for summary judgment was granted.

Violation Category: The two Plaintiffs suffer from bulimia and anorexia nervosa. They sought residential treatment for their eating disorders, but their health plans did not provide coverage for this treatment.

Short Description: Plaintiffs were both enrolled in health plans that cover mental illness, but exclude residential treatment. For both Plaintiffs, residential treatment was deemed medically necessary and residential treatment is widely seen as one of the most effective treatments for eating disorders. The Plaintiffs argue for a broad reading of the Parity Act’s “medically necessary treatment” language that includes residential treatment for anorexia and bulimia because there is no treatment analog for physical illnesses. By not adopting this reading, the Plaintiffs argue that the trial court failed to take into account the legislature’s goal of achieving parity. The Court declines to hold that parity mandates identical coverage for mental and physical illness.

Appeal/Disposition: The Court reverses the judgment of the trial court and finds that the language and background of the Parity Act require coverage for residential treatment of anorexia and bulimia.

Violation Category: Plaintiff’s 16-year old daughter had been hospitalized 9 times for acute inpatient care to treat her mental illness (PTSD, recurrent severe major depressive disorder and anorexia nervosa). Physicians had recommended she be transferred to a long-term residential treatment center. Plaintiff called to obtain preauthorization, Defendant denied based on the residential treatment center (RTC) exclusion in the plan. Plaintiffs claim this exclusion violates ERISA, which requires Parity. Defendant moved to dismiss on the ground that the statute did not apply to “treatment settings” during the time period at issue.

Short Description: Defendant argued that the federal Parity Act does not apply to nonquantitative treatment limitations, contrary to both the Interim and Final Rules, based on noscitur a sociis (questionable words and phrases in a statute may be ascertained by reference to the meaning of words and phrases associated with it) and ejusdem generis (where general words follow specific words in a statutory enumeration, the general words are construed to embrace only objects similar in nature to those objects enumerated by the preceding specific words). Defendant uses these concepts to argue that the phrase “other similar limits” only applies to numerical limitations. The Court did not agree with this argument. In the alternative, Defendant argues that if the federal Parity law does cover nonquantitative treatment limitations, it does not apply to treatment settings. This is based on the Departments declining to address the scope of services in the interim final rules. The Court again returned to the fact that the RTC exclusion had no similar basis for medical surgical benefits (i.e., if an elderly person broke their hip and needed nursing care in an RTC this would not necessarily be excluded).

Appeal/Disposition: Court denies the plan administrator’s motion to dismiss.