Kantor & Kantor is happy to announce that it has won an important victory in New Jersey on behalf of a woman with bulimia nervosa.
The woman, whose name is being kept anonymous to protect her privacy, began experiencing symptoms of her eating disorder when she was only eight years old. The eating disorder was left untreated for ten years. Over a two year period the woman cycled in and out of outpatient treatment, inpatient treatment, partial hospitalization treatment, intensive outpatient treatment and residential treatment. When she entered residential treatment for her bulimia 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 an evidentiary hearing to an Administrative Law Judge at the New Jersey Office of Administrative Law. Just recently, we received a ruling from the court fully 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 APA Guidelines at the time her claim was denied and throughout the remainder of her residential treatment, which lasted until March 2012. As a result, the court reversed the denial of benefits and ordered Magellan to pay the claim in full.
This woman is not alone; there are many eating disorder patients who are constantly battling with their insurers over benefits for their treatment. If you or someone you know needs help, please contact Kantor & Kantor for a free consultation.
We understand, and we can help.