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The Fight to Have Mental Illness Properly Covered by Insurance

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Los Angeles, CAAs patients with physical ailments fight to have their denied disability claims overturned, patients with mental illness also fight to receive proper treatment from insurance companies. Recent news reports and denied disability lawsuits allege some insurers in the US routinely discriminate against patients with mental illness, denying them medically necessary - and legally mandated - care.

In December 2014, CBS News reported on one case where an insurance claim was overturned following the start of treatment, resulting in the patient being released from the hospital over the objections of doctors. In this case, however, the patient had an eating disorder - and some patients are reportedly finding that their chronic claims are being reviewed and overturned by insurance companies based on the opinion of doctors who never lay eyes on the patient. Meanwhile, the people providing care to the patients are concerned that the early discharge is putting lives at risk.

The patient in the CBS story was Katherine West, who suffered from an eating disorder and had a history of cutting herself. Her doctors recommended hospital treatment at a cost of in excess of $50,000 for 12 weeks. After six weeks, Anthem determined, via a review doctor who did not ever see Katherine, that she had gained enough weight to safely leave the hospital. Katherine’s doctors - including a psychiatrist, pediatrician and therapist - objected, arguing that if she left, Katherine would continue with her harmful ways, which could result in her death.

Just a few days after Katherine was released as an outpatient from the hospital, she died of heart failure linked to her eating disorder.

Katherine’s case is not the only one where patients with a mental illness are forced to downgrade their treatment despite the concerns of their doctors because their claim has been denied or overturned. The CBS report cites several cases where patient care has been drastically reduced by the insurance company, with often disastrous results.

Lawsuits have been filed against insurers alleging they improperly deny claims for mental health coverage to save the company money. One lawsuit was filed against Anthem Blue Cross in August 2013, on behalf of policyholders who filed a claim for treatment of an eating disorder only to have full treatment denied.

That lawsuit, Shelby Oppel v. Anthem Blue Cross, alleges Anthem Blue Cross “wrongfully denied care for Ms. Oppel, and thousands of other eating disorder patients, in violation of the California Mental Health Parity Act, the Unruh Civil Rights Act, and the Medical Practices Act.” In the lawsuit, Oppel argues that the Parity Act requires insurers to provide “all medically necessary treatment for severe mental illness patients in parity with benefits for physical illness.”

The lawsuit argues that Anthem’s guidelines regarding eating disorders do not meet generally accepted standards of medical practice, are based on outdated references from as far back as the 1970s, and are discriminatory. Furthermore, the lawsuit argues that Anthem uses robosignatures on its denials - including on letters that physicians may not even see despite the letter containing their signature - and has a three strikes rule whereby treatment is automatically denied if the reviewer cannot speak to a doctor on the phone after three attempts at contact.

“Because there is no protocol in place for spacing out the three calls, peer physicians sometimes place all three calls in one hour,” the lawsuit argues. “Given that eating disorder therapists generally work in one hour sessions with their patients, Anthem’s response deadlines are often not met.”

The lawsuit is case number BC518736 in Superior Court of California, County of Los Angeles.


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