The 9th U.S. District Circuit Court of Appeals in August determined that Blue Shield of California is required to cover a policyholder’s inpatient treatment of her severe diagnosis of anorexia nervosa. The court made the decision based on the fact that California insurance providers are obligated under the state’s mental health parity law to cover the treatment of mental illnesses the same as it would for physical illnesses.
Forty-nine states and the District of Columbia all uphold mental health parity laws, although the laws differ from state to state. Some states only require that insurance providers simply offer mental health coverage as an option to policyholders in addition to their existing plans, while other states require insurers to equally cover treatments for both physical and mental illnesses, including substance abuse disorders. In 1999, California instated its Mental Health Parity law which obligates insurance providers to cover costs related to mental illnesses the same as it would for physical ailments; illnesses that fall under the categories of bipolar disorder, schizophrenia, schizoaffective disorder, obsessive-compulsive disorder, eating disorders, panic disorder, major depression, pervasive development disorder, autism, and serious emotional disturbances in minors must all be covered by California insurers. The new ruling in favor of the patient’s treatment for mental illness may significantly affect the mental health parity laws upheld by other states.
The case that brought about the court’s decision on Friday was that of 37-year-old policyholder Jeanene Harlick after she filed a complaint in 2008. Harlick had been suffering from anorexia for over 20 years, and in 2006 she began receiving intensive outpatient treatment for her illness. According to the U.S. 9th Circuit Court of Appeals in San Francisco, in March 2006 Harlick’s doctors informed her that the outpatient treatment wasn’t enough for her diagnosis, and instead required intensive inpatient treatment to help save her life. Anorexia nervosa is an eating disorder which causes an individual to maintain an unhealthily low body weight due to fear of gaining weight, in which he/she may abstain from eating, perform ritualistic habits like compulsively measuring calories, weighing food, or hiding uneaten food, and excessively exercise. According to the National Association of Anorexia Nervosa and Associated Disorders, eating disorders have the highest mortality rate of any mental illness.
Her insurance provider, Blue Shield of California, informed her that although hospitalization for a physical ailment that was medically necessary was covered under her plan, residential treatment for her condition was not covered. Blue Shield instead suggested to Harlick a list of potential hospitals where she could receive treatment under its plan, but Harlick’s doctors disagreed that the hospitals indicated were sufficient in providing Harlick the type of treatment she so badly needed. During that time, Harlick’s weight was merely 65% of her ideal body weight.
In April 2006, Harlick registered herself at Castlewood Treatment Center—an inpatient treatment facility in Missouri that specializes in eating disorders. Within the first month of her residency, Harlick required the use of a feeding tube to provide her the calories her body needed to survive. Meanwhile, Blue Shield refused to cover Harlick’s room and board costs. Harlick remained in residential treatment at Castlewood until January 2007. By 2008, Harlick filed the complaint with the federal district court, but the court ended up siding with Blue Shield, stating that the insurance plan unmistakably excluded coverage for residential treatment. Harlick then appealed the decision, and on Friday the U.S. 9th Circuit Court of Appeals’ three-judge panel sided with Harlick, overruling the lower court’s previous decision. In a 33-page opinion, the judges agreed that the Blue Shield plan did not cover residential treatment, but that Blue Shield’s denial of coverage for Harlick’s claims violated California’s mental health parity law. Due to the nature of Harlick’s treatment, which the judges said clearly indicated was medically necessary, the judges ruled that Blue Shield must pay for Harlick’s care.
A spokesperson for Blue Shield of California told the press that the insurer is still reviewing the court’s decision, but would not comment on the insurer’s future legal plans. If Blue Shield chooses to appeal the decision, the insurer could petition for a full 11-judge panel to hear the case, or would otherwise have to petition the U.S. Supreme court.
Lisa Kantor, Harlick’s lawyer, commended the court for its decision, which causes Blue Shield to now treat its statutes in a more broad sense. Kantor told the press that Harlick will be reimbursed for the care she received at Castlewood, an amount within the tens of thousands. During her illness, Harlick became so incapacitated that she lost her job and eventually her health insurance, and now depends on Medicare. However, Harlick is hoping to use the restitution to seek further treatment for her condition.