A California district court ruled that the state's Mental Health Parity Act requires an insu rer to pay for benefits for residential treatment for a client's major depressive disorder and panic disorder. Tbe coun cited an earlier landmark ruling in the state that challenged coverage in a residential facility related to an eating disorder. On Jan. 12 U.S. District Court Judge R. Gary Klausner ruled in Bur l01l v. Blue Shield of Cal ifomi a (BSC) that under the state 's Mental Health Parity Act, the insurer must cover medically necessary treatment of severe mental illnesses under the same terms and conditions applied to other medical conditions.... [ read more]
Kimberly Shepard, a young wife and mother, was in danger of losing her life from the debilitating effects of Anorexia Nervosa because her health insurer United HealthCare Insurance Company declined her claim for benefits to pay for residential treatment. Kantor & Kantor, LLP appealed to the California Department of Managed Health Care requesting that the DMHC immediately submit Shepard's case to an independent doctor for an examination and review after the U.S. District Court for the Eastern District of California denied Shepard's temporary restraining order to enjoin United HealthCare from continuing to withhold benefits.
Shepard sought treatment at Monte Nido residential treatment center in Calabasas, California, a preferred provider under Shepard's health policy. Although Shepard's condition more than met the policy's conditions for residential treatment, United HealthCare denied her claim. As a result, Shepard exhausted her family's financial resources to pay for treatment.
Within a month, the DMCH ruled that inpatient services at a residential treatment facility were medically necessary and ordered United Healthcare to resume payment for such care.
Thompkins v. BC Life and Health
Kantor & Kantor, LLP won the first published district court decision in California in an eating disorder case in which a client was denied benefits for in-patient treatment of bulimia. Thompkins v. BC Life and Health Ins. Co., 414 F.Supp2d 953 (C.D.Cal. 2006).
Amy Thompkins suffered from bulimia and required inpatient treatment at a residential care facility. After first agreeing to pay for such treatment, BC denied benefits after less that four months, saying Amy no longer required inpatient treatment despite assessments from her therapists that proved otherwise.
The District Court interpreted California's mental health parity law AB88, which requires health insurance policies to cover treatment for mental illness (including eating disorders) on the same terms and conditions applied to other medical conditions, to include beneficiaries who did not live or seek medical care in California but whose policies are issued in California. The court ruled Amy was entitled to continued benefits under her medical plan.
Harlick v. Blue Shield
NOTICE: ON AUGUST 26, 2011, THE UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT RULED IN FAVOR OF JEANENE HARLICK AND HELD THAT CALIFORNIA'S MENTAL HEALTH PARITY ACT REQUIRED BLUE SHIELD TO PAY FOR HER CARE AT A RESIDENTIAL TREATMENT FACILITY. READ THE COURT'S DECISION BY CLICKING HERE:
HARLICK v. BLUE SHIELD OF CALIFORNIA
Kantor & Kantor, LLP is challenging denial of benefits on behalf of Jeanene Harlick in an appeal to the 9 th U.S. Circuit Court of Appeals, which reviews cases that fall under the federal Employee Retirement Income Security Act, the law that governs employer-provided health plans.
Jeanene has suffered from anorexia for more than 20 years. Her physicians, backed by extensive research and professional recommendations, facilitated her admittance into residential treatment as perhaps the only option that could successfully treat her illness. After initially agreeing to coverage, Jeanene's health insurer Blue Shield of California refused to pay for the treatment because, they insisted, residential care is not covered in her policy. Whether or not this assertion is accurate is unclear because the policy is written is such a way that leaves the question of residential care coverage open. Indeed, Blue Shield changed its mind several times about what was or was not covered, and provided alternate and competing reasons for denial. And despite Jeanene's requests, Blue Shield never explained why the California Mental Health Parity Act did not require payment of her claim.
We have petitioned the 9 th Circuit to review and overturn the lower court's decision that Blue Shield did not abuse its discretion when it denied Jeanene's benefits. We assert that Blue Shield's statement that residential care is not covered, is a violation of California's Mental Health Parity Act.
We hope to see health plans apply California's Mental Health Parity Act and provide benefits to individuals seeking residential treatment for eating disorders. It would reinforce state law that mandates mental illnesses be treated under the same terms and conditions as other medical conditions. And it could enable thousands of people suffering from eating disorders to finally receive the comprehensive, often life-saving treatment to conquer their disease.
On July 12, 2012, the 9th U.S. Circuit Court of Appeals issued its final and binding decision in Lisa Kantor's most influential case to date. In Harlick v. Blue Shield, 686 F.3d 699 (2012), the court denied Blue Shield's
second request for rehearing of a significant decision in favor of people suffering from nine enumerated mental health conditions – Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, Major Depression, Obsessive-Compulsive Disorder, Panic Disorder, Eating Disorders (Anorexia Nervosa and Bulimia Nervosa), Autism or Pervasive Developmental Disorder, and Serious Emotional Disturbance in children and adolescents.
The court confirmed that California's Mental Health Parity Act requires health plans to provide coverage of "all medically necessary treatment" for "severe mental illnesses" under "the same financial terms as those applied to physical illnesses," and are obligated to pay for residential treatment for people with eating disorders even if the policy excludes residential treatment.
Harlick has been called a landmark decision and a turning point in the battle for insurance benefits to pay for residential treatment for people suffering from mental health conditions. Although the decision was issued in the context of anorexia, a district court cited
Harlickin January 2012 to rule in favor of benefits for residential treatment for another Kantor client suffering from major depression and panic disorder.
Burton v. Blue Shield,2012 U.S. Dist. LEXIS 13487. Advocates believe
Harlick will affect similar lawsuits and pending legislation around the country.
Kantor represented Jeanene Harlick, who has suffered from anorexia for more than 20 years. In 2006, her physicians recommended treatment at a facility qualified to treat eating disorders. Although Blue Shield agreed to pay for the treatment, after 10 days it denied coverage, saying the plan did not cover residential treatment even though the insurer agreed the treatment was medically necessary.
In July 2008, Kantor sued Blue Shield on Harlick's behalf, arguing, among other things, that Blue Shield's health plan violated the California Mental Health Parity Act. Blue Shield argued that it properly denied coverage under the terms of the plan, and the district court agreed. Harlick appealed, and the 9th Circuit ruled in her favor in August 2011.
Blue Shield requested a rehearing and a rehearing en banc. On June 4, 2012, the Court denied the request, withdrew its prior opinion of August 26, 2011, and issued a majority opinion by Judge William A. Fletcher with a dissenting opinion by Judge N.R. Smith. Blue Shield immediately filed another request for rehearing and rehearing
en banc, which was denied in July 2012.