Skip to main content

Kantor & Kantor, LLP recently shared the wonderful news about a victory achieved on behalf of one of our clients who had been denied insurance benefits for the treatment of her conditions that included anorexia nervosa, depression, anxiety, OCD and self-harm. This blog explains a bit more about how a case like Jamie’s works, as well as expounds on the meaning behind the Judge’s decision.

Background: Our client Jamie suffered with several illnesses, including an eating disorder, specifically anorexia nervosa, depression, anxiety, self-harm and OCD. Eventually, Jamie was hospitalized due to complications from her conditions. At the end of a week of treatment in the hospital, her doctors informed Jamie that she required residential treatment in order to continue her healing. Jamie’s outpatient treatment team felt that the best treatment center for Jamie’s symptoms and conditions would be Avalon Hills Eating Disorder Treatment Center, in Utah.

Jamie’s health insurance benefits were provided through United Healthcare Insurance Company (“United” or “UHC”). Rather than authorize Jamie’s treatment, United said that they needed to send her case to what is referred to as a Peer to Peer review. Peer to Peer reviews are supposed to be an opportunity for equally qualified peers to discuss (review) whether a patient’s treatment is medically necessary. Unfortunately, the “peer” from the insurance company oftentimes lacks expertise in the diseases and conditions that a patient is suffering.

The Denial: Despite the fact that Jamie’s doctors all stated that Jamie required residential treatment, and despite that when Jamie admitted to Avalon Hills she was suffering from malnutrition and bradycardia, she was refusing food and losing weight, and she met the diagnostic criteria for generalized anxiety disorder, obsessive compulsive disorder, and anorexia nervosa, restricting type, extreme, the peer review doctor from United said that Jamie’s treatment was not medically necessary. In a letter dated February 27, 2018, United issued their denial. The February 27, 2018 denial letter quoted the peer reviewer, a doctor who had never met with, spoken to, or examined Jamie, and it read:

I have determined that coverage is not available under your benefit plan…You do not seem to need residential treatment for your eating disorder. Your weight is stabilizing. You are now medically stable. You are not reported to be at risk of harm to yourself or others. There is no indication that you need 24[-]hour medical or psychiatric care. It seems you could work towards recovery at the partial hospital level of care. Based on Optum Level of Care Guidelines for MENTAL HEALTH Residential LEVEL OF CARE, it is my determination that authorization cannot be provided as of 2/22/18. It seems that treatment could continue at the mental health/eating disorder partial hospital level of care.

The Appeal: Jamie and her family contacted Kantor & Kantor to see if we could assist them with appealing the denial. On April 11, 2018, we submitted an extensive appeal letter on Jamie’s behalf. With her appeal letter, we submitted copious amounts of information that supported Jamie’s need for residential treatment. That information included Jamie’s medical records from Avalon Hills and records from her outpatient providers. In addition, we submitted four separate letters from Jamie’s doctors who treated her prior to her receiving treatment at Avalon Hills. The letters from her doctors delineated in great detail why Jamie required more than just the partial hospitalization treatment recommended by United’s peer reviewer. In fact, one of the letters was written by Jamie’s doctor who had treated her while she was receiving inpatient (acute) treatment just one week before being transferred to Avalon Hills. That doctor wrote, “[Jamie] would very likely be quickly readmitted for medical instability” without the treatment such as what she was receiving at Avalon Hills. Another letter was from Jamie’s doctor who had treated Jamie since 2015. She wrote, “…if not treated appropriately and at the adequate level of care (residential treatment in this case) puts Jamie at a higher risk for prolonged relapse and premature death.”

The appeal and supportive documentation made it obvious that Jamie’s need for residential treatment was medically necessary, and in fact showed that Jamie risked dying if she did not receive such treatment. Despite this, United denied Jamie’s appeal.

The Appeal Denial: In a May 20, 2018 letter, another doctor (on behalf of United) who had never met with, spoken to or examined Jamie, summarized that because Jamie was “90% of her ideal body weight, calm and cooperative, and not self-harming,” he was denying her appeal. In essence, the doctor that United had review Jamie’s request for benefits went against all of the professional opinions of Jamie’s treatment providers.

The Next Step -Litigation: After the May 20, 2018 denial letter came in from United, Jamie’s family decided to fight back, and they asked Kantor & Kantor to sue United on their behalf. Therefore, on February 28, 2019, Kantor & Kantor Partner Elizabeth Green filed a complaint in the U.S. District Court, in the Northern District of California, on Jamie’s behalf.

A “complaint” is a formal document that is filed with the Court and is the beginning of a lawsuit. The complaint is a written document that a plaintiff (in this case, Jamie) submits against a defendant (in this case, United) and it details how the plaintiff’s legal rights were violated by the defendant. The complaint also outlines what the plaintiff is asking for to remedy the wrongdoing. The complaint then must be served to (given to) the defendant so that they know that they a) are being sued, and b) why they are being sued. The defendant must respond to the complaint with an answer.

In short, United’s answer to Jamie’s complaint said that while United did not challenge the opinions of Jamie’s treating physicians and they did not contest the American Psychiatric Association Guidelines (“APA Guideline”) cited by Jamie’s treating physicians, United felt that their own internal guidelines were sufficient to assess Jamie’s need for residential treatment. To note, the APA Guideline, not United’s internal guidelines, are the standard of care in the treatment community.

Jamie’s case was then assigned to a judge,[1] the Honorable Yvonne Gonzalez Rogers. Judge Gonzalez Rogers would ultimately review Jamie’s case “de novo.” De novo is Latin for “from the new.” When a court hears a case “de novo,” it is making decisions about the complaint without deference to previous findings, as if the case were being reviewed for the first time – reviewed anew.

On February 11, 2020, Kantor & Kantor’s Elizabeth Green provided oral argument to the Court. United’s counsel did, as well. Following such, on July 23, 2020, Judge Gonzalez Rogers issued her decision on Jamie’s case.

The Decision: Judge Gonzalez Rogers’ July 23, 2020 decision (“Order”) granted “motion for judgement in favor of the plaintiff.” That means that, after reviewing Jamie’s case “de novo,” Judge Gonzalez Rogers concluded that United was wrong to deny Jamie benefits for her treatment. AKA: we won! Beyond being very glad to have prevailed on Jamie’s behalf, we were also very gladdened by the verbiage within the decision issued by Judge Gonzalez Rogers. Her decision contained several notable and poignant points. We encourage you to read the full decision (which btw is very readable even if you are not an attorney!), but here are a few of our favorite points:

  1. Judge Gonzalez Rogers called out United’s reviewer (Dr. Sane) out for not doing a remotely thorough review of Jaime’s history or medical records: “It is unclear from Dr. Sane’s notes whether she reviewed any of plaintiff’s medical records, including those from Stanford, in making this initial review…Dr. Sane’s notes do not indicate whether she was aware that plaintiff had previously been hospitalized in 2015 and discharged to a partial hospitalization program which proved unsuccessful, resulting in plaintiff needing to be transferred to residential treatment for several months.” (p.7 at 23-28)
  2. Judge Gonzalez Rogers also called out United’s (UHC) reviewers for pretty much ignoring Jamie’s medical records and doctor’s opinions: “First, to the extent that UHC suggests that plaintiff’s appeal should be denied because its reviewers’ determinations were supported by substantial evidence, it misapprehends the applicable standard here…Moreover, the preponderance of the evidence in the record indicates that UHC’s reviewers failed to consider the medical opinions of plaintiff’s treating physicians or to conduct a thorough review of the medical evidence.”[emphasis added] (p. 12 at 8-16)
  3. Judge Gonzalez Rogers then called out United’s reviewers for discounting Jamie’s conditions and her suffering: “Further, UHC’s determinations relied on characterizations of plaintiff’s diagnoses, symptoms, and severity which omitted or were at odds with the information in her medical records from her Stanford hospitalization and Avalon Hills’ intake. Dr. Sane’s summary of the information provided by Avalon’s staff significantly understates and omits…Rather than account for treating physicians’ opinions or the medical records indicating the severity of her symptoms and co-morbid diagnoses, UHC’s reviewers appear to have focused entirely on their own assessment…” (p. 13 at 21-28; 14 at 1)
  4. Judge Gonzalez Rogers had another awesome footnote that outlined how United ignored its own internal guidelines: “Lack of current suicidal ideation is not a criterion for deciding whether between residential or community treatment, but instead is a factor for deciding whether inpatient hospitalization is needed, even under UHC’s own guidelines.” (p. 14 at 26-28)
  5. Judge Gonzalez Rogers’ decision reaffirmed[2] the disapproval of the medical necessity guidelines that United used to assess (and deny) Jamie’s need for benefits for treatment: “However, the Court finds reasons to doubt the Optum Guidelines can be relied upon as a statement of generally accepted standards of medical practice in the present context. First, several recent decisions have found that the Optum Guidelines are not consistent with any generally accepted standards of medical practice, including a sweeping, comprehensive review by the court in the Wit class action challenging the Optum Guidelines, among others…Second, the Optum Guidelines nowhere mention or reference eating disorders, nor do they reference any scientific literature or professional standards concerning eating disorders [emphasis added] (p. 15 at 2-6; p. 16 at 4-5)

Perhaps most notable for Jamie and her family were these vindicating words that Judge Gonzalez Rogers wrote:

The Court finds that the preponderance of the evidence in the administrative record demonstrates plaintiff was entitled to coverage under the Plan. Based upon a thorough review of the record including: plaintiff’s diagnosis of Anorexia nervosa, severe; her co-morbid diagnoses of anxiety, depression, obsessive-compulsive disorder; her treatment history; her medically fragile state; and the recommendations of her treating physicians based upon medical standards, the Court concludes that residential treatment at Avalon Hills was medically necessary...” [emphasis added] (p. 11 at 11-17)

Conclusion: To fight back against an insurance company is not easy for an individual or a family, especially when you or a loved one is in treatment and fighting for life. We want to thank Jamie and her family for their perseverance, patience, commitment, gumption, and “never give up” attitude. We especially thank Jamie and her family for the trust they placed in our firm as we worked on their behalf. Jamie and her family are two of the very important reasons why we will continue to do the work we do.

We know that seeking treatment can be a daunting endeavor, especially with the high rate of denial. But we encourage you to seek the treatment you need and deserve. As Elizabeth Green said about Jamie’s decision: “The decision marks continued progress in holding insurance companies like United accountable to apply accepted medical standards to coverage decisions in the best interests of patients like Jamie.”

If you are denied benefits for treatment, a procedure, or even medication, please contact us for a free consultation or use our online contact form.

We are here to help you hold your insurance company accountable.

[1] The “next steps” after a complaint is filed are many. This blog does not mention or discuss each and every step or detail. We welcome you to contact us with any questions about the litigation process.

[2] Judge Gonzalez Rogers cited three other recent cases against United that also disapproved of the guidelines: (Wit v. United Behavioral Health, No. 14- CV-02346-JCS, 2019 WL 1033730 (N.D. Cal. Mar. 5, 2019), S.B. v. Oxford Health Ins., Inc., No. 3:17-CV-1485 (MPS), 2019 WL 5726901 (D. Conn. Nov. 5, 2019) and Bain v. Oxford Health Ins. Inc., No. 15-CV-03305-EMC, 2020 WL 808236, at *10 (N.D. Cal. Feb. 14, 2020).