Our client is a young woman who entered residential treatment for bulimia nervosa in September 2011. Prior to September 2011, her eating disorder went untreated for ten years. Over the two year period prior to September 2011, the young woman cycled in and out of outpatient treatment, inpatient treatment, partial hospitalization treatment, intensive outpatient treatment and residential treatment. When she entered residential treatment in September 2011, the facility submitted a claim for benefits to her insurance company, Horizon Blue Cross Blue Shield of New Jersey.
Horizon and its behavioral health managed care partner, Magellan Behavioral Health, paid for the first three weeks of treatment, but refused to pay past that date, contending that the treatment she was receiving was no longer "medically necessary."
Kantor & Kantor filed several internal appeals. After years of appeals, Kantor & Kantor presented the case 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. In June 2017, the Judge issued a ruling in our client’s favor. The Judge entered several important findings.
First, the Judge found that the opinions of the treating physicians were entitled to greater weight as opposed to physicians who are employed by insurance companies for the mere purpose of making administrative decisions without any personal examination of the insured.
Second, the Judge found that Magellan’s utilization review and coverage determinations were “perfunctory at best, and wholly failed to take into account the treating team’s on-the-ground medical opinion….Five or ten minutes of discussion, review or analysis at each stage is hardly befitting a case as complex…” The Judge went on to point out that Magellan’s “one (skimpy)-size-fits-all approach” is “patently absurd and in-credible.”
In conclusion, the Judge ruled that Magellan’s decision was wrong. The Judge found that the woman met both the Magellan Medical Necessity Criteria and the American Psychiatric Guidelines for the Treatment of Patients with Eating Disorders at the time her claim was denied and throughout the remainder of her residential treatment, which lasted until March 2012. As a result, the Judge reversed the denial of benefits and ordered Magellan to pay the claim in full.
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 Commission remanded the case back to the New Jersey Office of Administrative Law with five questions that it wanted addressed. From October 2017 through June 2018 both parties briefed their responses to the questions posed by the Commission and presented their facts in written documents to the Judge. On December 12, 2018, the Judge closed the remand record.
On January 11, 2019, the Judge issued her remand decision upholding the prior decision in our client’s favor. The Judge once again reiterated that all of the treatment at issue was medically necessary and the Magellan’s utilization review and coverage determination process “merely institutionalizes a rubber-stamp approach to claim denials.” Another important victory in New Jersey for Kantor & Kantor and for all individuals suffering from eating disorders.
KANTOR & KANTOR, LLP'S EATING DISORDER PRACTICE
Dealing with and seeking treatment for eating disorders can be emotionally and financially devastating, but it doesn't need to be that way. Kantor & Kantor, LLP has developed a specialized legal practice representing clients whose claims for treatment of eating disorders have been wrongfully denied by their insurance company. If you have been denied treatment for an eating disorder by your insurance company, we can help. Call (818) 886-2525 or contact us online to learn more about how we can help you. We offer no-cost consultations, and we work on a contingency fee basis, which means you don't pay us a fee unless we get your claim paid.