While this story certainly involves denial of healthcare benefits, insurance, mental health parity, and questionable legal tactics, this is actually a story of waste at the expense of children of New Jersey state employees.
GC suffered from anorexia nervosa. She received residential treatment for her eating disorder at Avalon Hills Residential Eating Disorders Program (“Avalon Hills”) in Logan, UT from November 30, 2009 through her discharge of November 5, 2010. Over the two year period prior to November 2009, GC cycled in and out of outpatient treatment, inpatient treatment, partial hospitalization treatment, intensive outpatient treatment and residential treatment.
JF suffered from bulimia nervosa. She received residential treatment for her eating disorder at Avalon Hills from September 15, 2011 through her discharge on March 12, 2012. Prior to September 2011, JF’s eating disorder went untreated for 10 years. Over the two year period prior to September 2011, JF cycled in and out of outpatient treatment, inpatient treatment, partial hospitalization treatment, intensive outpatient treatment and residential treatment.
Both girls were insured as dependents on their parents’ NJ Direct plans issued to employees of the State of New Jersey. Both plans were administered by Horizon Blue Cross Blue Shield of New Jersey (“Horizon”). Magellan Behavioral Health administered claims for mental health benefits.
In both cases, Magellan and Horizon denied authorization for ongoing residential treatment. In GC’s case, ongoing treatment was denied from February 9, 2010 through November 5, 2010 (190 days of treatment). In JF’s case, ongoing treatment was denied from October 10, 2011 through March 20, 2011 (166 days of treatment). In both cases, Magellan and Horizon determined that ongoing treatment was no longer “medically necessary.” In GC’s case, they also erroneously applied a mental health benefit maximum and concluded that benefits were no longer available.
The treatment saved these girls’ lives.
In both cases, Kantor & Kantor spent years filing internal appeals as required by the New Jersey Direct plans. JF’s case was finally presented during several evidentiary hearings which took place in April, July, and August 2016 before an Administrative Law Judge at the New Jersey Office of Administrative Law (“OAL”). In June 2017, the Judge issued a ruling in JF’s favor. In September 2017, the New Jersey State Health Benefits Commission (“the Commission”), under statutory authority, decided to remand the matter without issuing a final decision. The case was remanded back to the OAL with five questions that it wanted addressed. Both parties briefed their responses to the questions raised by the Commission. On January 11, 2019, the Judge issued her remand decision upholding the prior decision in our client’s favor. On May 24, 2019, the Commission issued their Final Administrative Determination adopting part of the Judge’s decision and modifying part of the Judge’s decision. On July 2, 2019, Kantor & Kantor filed an appeal with the New Jersey Superior Court, Appellate Division.
GC’s case was set to be heard by a Judge at the OAL from July 1, 2019 through July 3, 2019. On June 28, 2019, the Commission stayed the case and removed jurisdiction from the Judge assigned to the case.
As of this writing the case is back with the Commission on request for interlocutory review by the Respondent. Kantor & Kantor has requested to be placed on the agenda for the next scheduled meeting of the Commission on July 24, 2019 to discuss the merits of this case and address the issues raised by the Respondent in their request for interlocutory review.
Kantor & Kantor continues to fight for both of these girls and their families as well as several other clients whose cases have been unjustly delayed in the bureaucracy of the New Jersey Division of Pensions and Benefits health benefits system. When this baked-in waste of time and resources is so egregious, AND it affects children, we feel like people should know.