The joys of private health 'care' in the US II

Insurer Sued for Refusing to Pay Costs of Anorexia

By TINA KELLEY

Published: November 9, 2006

NEWARK, Nov. 8 — A New Jersey couple filed suit against Aetna Inc., the Hartford-based insurance company, on Wednesday, claiming that it refused to fully cover their daughter’s treatment for anorexia.

The suit was filed in United States District Court here. The couple, Cliff and Maria DeAnna of Mountainside, N.J., said Aetna refused to pay for nearly 10 weeks of their daughter’s inpatient treatment, saying her eating disorder was not “biologically based.” Insurers have balked at covering mental illnesses that they say do not have a proven physiological basis.

Ms. DeAnna, who declined to provide her daughter’s given name for privacy reasons, said by phone that she had been hospitalized for 101 days so far this year but that Aetna U.S. Healthcare H.M.O. would pay for only 35 inpatient days. Symptoms of anorexia include excessive dieting and exercise and a distorted belief that one is overweight.

The case is an example of what advocates for the mentally ill call longstanding inequities in insurance coverage for psychological ailments. The family’s lawyer, Bruce Nagel, said state law required insurers to provide the same coverage for mental and nervous conditions as for physiological diseases, like heart ailments or emphysema. The suit estimates that hundreds of people in New Jersey have had similar difficulties receiving coverage, and it seeks certification as a class action. Ms. DeAnna estimates that her family has paid almost $100,000 in medical bills this year alone, with the help of a home equity loan. Her daughter, who is 20 and stands 5-foot-6, weighed 102 pounds when she last went into the hospital.

A spokeswoman for Aetna, Cynthia B. Michener, said the company had not yet been served with the suit and could not discuss a particular case without written authorization from the family involved.

Anorexia has a high mortality rate, said Lynn Grefe, the chief executive of the National Eating Disorders Association, a nonprofit group based in Seattle.

While many lawmakers and insurance companies have struggled to define anorexia, some medical experts question the usefulness of the term “biologically based” to describe a disease. Ms. Grefe said that Thomas R. Insel, the director of the National Institute of Mental Health, which is part of the National Institutes of Health, has said research has established that the disease is a brain disorder.

“While the symptoms are behavioral, this illness has a biological core, with genetic components, changes in brain activity and neural pathways currently under study,” he wrote in an Oct. 5 letter to her.

Ms. Grefe said she was not aware of any other class-action suits seeking insurance coverage for anorexia, “but it’s about time.”

According to the National Association of Anorexia Nervosa and Associated Disorders, a nonprofit organization based in Highland Park, Ill., a judge in a 1989 case against Blue Cross and Blue Shield of Greater New York ruled that starvation resulting from anorexia is a physical state that should be covered by medical benefits.

In 2001, Blue Cross and Blue Shield agreed to pay $8.2 million to the state of Minnesota to settle a suit filed by the state involving treatment denied to a 21-year-old anorexic woman who committed suicide. Her family paid for her treatment but sued Blue Cross for refusing to pay for it. The insurer also settled with the family for $1 million.

From the New York Times