Insurer Sued for Refusing to Cover Care for Anorexia

Insurance company Aetna was sued by a New Jersey couple for refusing to cover their daughter's care for anorexia.

The New York Times reported on the lawsuit, filed in in United States District Court in New Jersey.

The daughter allegedly had nearly 10 weeks of inpatient treatment; the insurance company declined coverage, on the grounds that her eating disorder was not "biologically based."

The Times notes that "insurers have balked at covering mental illnesses that they say do not have a proven physiological basis," and that this case exemplifies "what advocates for the mentally ill call longstanding inequities in insurance coverage for psychological ailments."

The line between physiological and psychological may be less solid than what insurers, in the name of staving off possible insurance liabilities, may think it is.

Particularly in an age that has coined the term "mind-body" and recognized that, beyond 'placebo' and 'psychosomatic,' there are real connections between environment and mood, affect, and behavior, and that--as some theories of alternative medicine (such as traditional oriental medicine, Ayurveda, and energy healing) assert, disease begins in imbalance and ultimately manifests in physiological disturbance.

Some years ago, a series of cases arose involving patients seeking reimbursement for unconventional cancer treatments by Dr. Burzynski. Insurance companies tried to avoid coverage on the ground that contractually, they could not cover therapies that were not "medically necessary," or that were excluded as "experimental."

The same argument was tried -- successfully in a number of cases -- with therapies involving nutritional approaches to cancer treatment, and other holistic or complementary and alternative medical therapies. (The cases are discussed in Complementary and Alternative Medicine: Legal Boundaries and Regulatory Perspectives (1998)).

In the lawsuit regarding failure to cover costs of care for anorexia, the Times reports that the family lawyer "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."

The plaintiff allegedly incurred almost $100,000 in medical bills in one year alone.

The causes of the condition remain debated. And indeed: "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." The article quotes Thomas R. Insel, the director of the National Institute of Mental Health, which is part of the National Institutes of Health, for stating that "research has established that the disease is a brain disorder," and writing that: "'While the symptoms are behavioral, this illness has a biological core, with genetic components, changes in brain activity and neural pathways currently under study.'"

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Law Offices of Michael H. Cohen offers general corporate legal services, litigation consultation, and expertise in health law, with a unique focus on alternative, complementary, and integrative medical therapies.

Michael H. Cohen is also President of the the Institute for Integrative and Energy Medicine, also known as the Institute for Health, Ethics, Law, Policy & Society. The Institute serves as a reliable forum for investigation and recommendations regarding the legal, regulatory, ethical, and health policy issues involved in the judicious integration of complementary and alternative medical therapies (such as acupuncture and traditional oriental medicine, chiropractic, massage therapy, herbal medicine) and conventional clinical care.

The most recent book written by Michael H. Cohen on health care law, regulation, ethics and policy pertaining to complementary and alternative medicine and related fields is an interdisciplinary collection of essays entitled, Healing at the Borderland of Medicine and Religion.

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