Kantor & Kantor is happy to announce that it has won an important victory on behalf of a young woman with bulimia nervosa.
The woman, whose name has been kept anonymous by the court due to her young age, entered residential treatment for her bulimia in 2012. She submitted a claim for benefits to her insurance company, Anthem Blue Cross and Blue Shield.
Anthem paid for the first twenty days of treatment, but refused to pay past that date, contending that the treatment she was receiving was no longer "medically necessary."
Kantor & Kantor challenged that decision in federal court in Maine, and recently received a ruling from the court fully in her favor. The court ruled on two important issues.
First, the court found that Anthem's decision was not entitled to any deference. Often, an insurance company will contend that its decisions are entitled to deference because the benefit plan at issue contains language granting it "discretionary authority" to review benefit claims.
While the policy in this case contained "discretionary authority" language, the court fortunately agreed with us that it could not be enforced. Maine, like many states, has been cracking down on insurance companies who attempt to give themselves a deferential shield in court, and has passed a law banning so-called "discretionary clauses". The court ruled that this law applied to Anthem's insurance policy and refused to give its decision any deference.
Second, the court ruled that Anthem's decision was wrong. The court found that Anthem had used the wrong criteria in deciding the claim, had mischaracterized telephone calls with treatment providers, offered "conclusory" rationales for its decision, and gave the claim "short shrift," among other findings. As a result, the court ordered Anthem to pay the claim in full.
This young woman is not alone; there are many eating disorder patients who are constantly battling with their insurers over benefits for their treatment. If you need such help, please contact us.
We understand, and we can help.