Residential Treatment for Eating Disorders: What Does Your Doctor Need to Say?

Slate.com had a great article recently by Katy Waldman talking about anorexia, and the potentially damaging narratives that even those in recovery from anorexia tell themselves.  As she writes: "[t]he anorexic impulse to lyricize one’s illness is a prescription for estrangement, for controlling and muffling the messy truths about who we are."

In the article, she calls for treatment that addresses the physical issues resulting from eating disorder: nutrition and weight restoration, rather than trying "to crack some psychological code—to unearth the mysterious psychic forces driving the illness "  

Whatever type of treatment a patient and his or her doctors want to pursue, obtaining insurance coverage for treatment of anorexia, bulimia and other eating disorders is challenging.  As with many issues with ERISA health benefits and group health insurance, what you think should work frequently doesn't.

In Connecticut, residential treatment of eating disorders, substance abuse and psychiatric illness has been difficult because there were no residential treatment programs for adolescents in the area.  There is now residential treatment for adolescents in Fairfield County, at Silver Hill Hospital, which I discussed in a prior blog post.   But, I believe we will still have many insurance companies denying coverage for residential treatment, even with a local provider.

So, what does your doctor need to say to get coverage for residential treatment of eating disorders, whether it is the "crack the psychological code" treatment or treatment addressed directly to the physical issues of eating disorders that Katy Waldman endorses?

• Typically, a doctor will tell you that:

Residential treatment is the best way for your daughter to recover

That should do it, right?  Nope.  

• What if your doctor tells you:

Residential treatment is the only way for your daughter to recover

That's got to do it, doesn't it?  The purpose of the policy is to provide treatment to cure problems, so if the treatment is medically necessary for the patient to get better, doesn't the insurance company have to pay for it?  

Still nope.  Under most health insurance policies, to get residential treatment for eating disorders, or for substance abuse treatment, or most any psychiatric illness, the doctor has to tell you:

Residential treatment is the only only way to protect your daughter from a serious risk of imminent death or serious injury to herself or others. 

I will post more in in the future about what specifically you need to do to make the best case for residential treatment for eating disorders, substance abuse treatment or other psychiatric issues, including the arcane treatment protocols that you have to follow to get benefits.  But, reviewing the policy and the incorporated treatment protocols before the claim is submitted will give you the best chance to get insurance coverage for residential treatment of eating disorders in Connecticut or in another state.   

An experienced health benefits attorney can help you get coverage for the treatment that you and your doctors think is best for treatment of eating disorders or other residential treatment.  

Residential Treatment for Eating Disorders Now Available in Connecticut

Patients and their parents in Connecticut have frequently encountered great difficultly in obtaining the residential treatment for eating disorders recommended by their doctors.   In the past, residential treatment of eating disorders was only available out of state.  Insurers fought hard to not cover out-of-state treatment, and I think the expense of out-of-state treatment was one reason for that.  I will discuss coverage for eating disorders in a upcoming post, and grounds for appealing a denial of benefits for residential treatment of eating disorders.  

Connecticut now has a residential treatment program for eating disorders.  Silver Hill Hospital in New Canaan recently started offering residential treatment.  I hope with in-state treatment available, it may be a little easier to obtain coverage for residential treatment of eating disorders in Connecticut.  It will still be a fight, but maybe we will start a little closer to the goal.  

What Is ERISA? Welfare Benefits: Disability Benefits; Health Insurance; Severance Claims

As discussed in the prior post, ERISA governs almost all employee benefits, including non-pension benefits like LTD benefits, severance, and medical insurance.   These non-pension benefits were included in ERISA as an afterthought, and not many provisions of the law itself addresses them.  Over the forty years ERISA has been in effect, however, the courts have developed a complicated structure to apply ERISA to non-retirement benefits, a structure which the courts regularly change.  This is another one of the areas that makes ERISA complex.

With a Connecticut LTD denial, an attorney has many options in suing in court or pursuing a remedy with the Connecticut Department of Insurance.  With an ERISA LTD case, or other ERISA benefit claim, there are a different set of rules.  

• ERISA does not require that a company offer any particular benefits, or require that any particular class of employees be covered.  So, a company doesn’t have to offer severance benefits, and can decide that some employees (for instance, part-time employees) are not entitled to benefits.  As with everything with ERISA, there are exceptions to this, particularly regarding health insurance after Obamacare, and limitations on favoring highly compensated employees.  But generally, employers get to offer what they want to, and they don’t have to fair about it.

• Welfare benefits, as opposed to pension benefits, don’t vest.  That means until an employee earns the right to get a particular benefit, the employer can change or eliminate the benefit.  Pension benefits, on the other hand, cannot be changed once the benefits vest, even if the employee is not yet receiving pension payments.  So, the day before you are laid off, the employer can eliminate a severance plan, and there is nothing you can do about it.  As with everything with ERISA, there are exceptions: once you have started to receive benefits, the employer can’t take them away.

• Prior to going to court to get benefits, you must exhaust any appeal rights that exist with the plan.  Nothing in ERISA requires this appeal, but the courts require it in almost every case.  So, after the plan denies your severance claim, health insurance claim, LTD claim or other welfare benefit, you must write the employer and ask them to change its mind.  Once the courts imposed the requirement, the Department of Labor issued regulations requiring plans to provide a fair and unbiased review of the denial.  Anyone who has been following this blog knows how important the administrative appeal is.  Even though it is not required by ERISA itself, it is one of the most important things in getting benefits that have been denied.  It is an example of the dangers ERISA presents to inexperienced lawyers.

Regarding health insurance, the Affordable Care Act, or Obamacare, has changed the landscape for denied medical benefit claims in many cases.  See my post on this here, and my post on the Supreme Court’s decision in King v. Burwell upholding key provisions of the act here.

Despite the changes made by Obamacare, plan participants in Connecticut and elsewhere with medical benefit claims, long and short disability benefit claims and severance claims, will have to go through the ERISA maze to vindicate their rights to benefits.  Make sure you have a guide in the maze who has been there before.

Supreme Court Comes Through For Obamacare!

If you are interested enough in the topics I discuss in this blog, you probably already know that the Supreme Court, in the case of King v. Burwell, upheld the health insurance subsidies that are a key part of Obamacare.  In my civilian life as a liberal democrat and strong supporter of President Obama, I am happy with the decision.

But, as a Connecticut ERISA lawyer, I am happy for what the decision means for my clients.  For all the problems with insurance that I discuss in this blog, insurance is a good thing, and good insurance is a great thing!  Obamacare, or more formally the Affordable Care Act, is achieving its goal of increasing the number of insureds, and making sure that insurance is more likely to cover the expenses from a serious health condition.  You may need my help, or another ERISA attorney, to appeal an insurance company's denial of a medical claim.  I would rather have that fight, though, then try to keep a hospital from foreclosing on your house for unpaid medical bills. 

The Act does other good things.  For years prior to the Act, I had clients who used up their COBRA, or couldn't afford COBRA, and had preexisting medical conditions that prevented them from buying private insurance.  Or, once they lost their jobs, they had no way of affording health insurance, but now, they can get subsidies on the health exchanges.  

There are problems with the law, of course. and any program as huge as Obamacare will have problems with implementation.  But with the Supreme Court's decision today, the question of the legality of the Act should be over, and opponents and supporters can work together to make the law more effective and fair.  

Health Insurance Doesn't Always Protect You From Big Bills

The New York Times has a post today on people who have health insurance, but are underinsured, defined as paying more than 10% of income towards medical bills.  One of the reasons people who are insured still have big medical bills is that the insurance company denies medical claims that they should pay.  They deny claims for many reasons, including that the requested treatment is not medically necessary, or is experimental, or the requested treatment is out-of-network and the insurer claims equivalent treatment is available in-network, even though your doctor disagrees.   This can occur with both private insurance, and insurance through an employer that is governed by ERISA

If an insurer does deny on a claim on these basis, you do have remedies that can keep you out of the ranks of the underinsured.:

• You can file an appeal with the plan.  This is a crucial step.  You cannot pursue any of your other remedies until you file the appeal with the plan.  Also, it may be your only chance to submit information in support of the appeal.  Having an  experienced Connecticut ERISA lawyer to handle the administrative appeal can help to make sure you have all the information in the file to succeed at the later appeal levels.  
• For appeals of denied health insurance claims in Connecticut, you can file an appeal with the Connecticut Department of Insurance. .  Here is a link to a guide to the process.  The Affordable Care Act requires states to establish procedures for appeal of denial health insurance claims, so there should be a similar process in your state if you are not a Connecticut resident.  
• If these don't succeed, you have the option of pursuing your claim in court: in federal court for ERISA claims arising from plans established by your employer; or state court if you purchased the plan directly.  Whether you have a good claim in court depends largely how complete your prior appeals were, so be careful with the appeals!

Insurers do not always pay the claims they should pay under the policy.  By effectively appealing the decision, you can increase the chance you will avoid the big bills that will make you underinsured.  An experienced employee benefits attorney in Connecticut or your state can be a big help in making this happen.

Denied Health Benefits under an ERISA Health Insurance Claim? Obamacare Can Help

President Obama’s health care law, the Patient Protection and Affordable Care Act (“ACA”), also known as Obamacare, requires health insurance claims to provide for external review of many types of denials of health benefit claims under group health insurance policies governed by ERISA.  An explanation of the final rules can be found here. 

For more than thirty years, ERISA health insurance plans had to provide for an internal administrative review of health benefit claim denials, a process that a claimant had to pursue before bring suit in federal court for a health claim denial.  The ACA added a significant improvement in the existing, pre-litigation review process for ERISA health plan denials.  It requires plans to offer an external review process for health insurance benefit denials, conducted by an independent third party.  The external review process is available when the denial involves application of medical judgment such as medical necessity, level of care, and experimental or investigational treatment, and whether the health care setting (out-patient, or intensive out-patient, or residential treatment) is appropriate.  I have found the process particularly useful in appealing denials of residential treatments for eating disorders or substance abuse treatment for teens.  The external review process occurs after you have exhausted the plans administrative appeals.  In addition to the claim file, the external review will consider new arguments and documents you submit with the request, so the request should be carefully completed to make it as effective as possible.  

In my Connecticut ERISA appeal practice, I have found the process particularly useful in appealing denials of residential treatments for eating disorders such as bulimia or anorexia or drug or alcohol substance abuse treatment for teens.  Connecticut does not have facilities offering residential treatment in these areas, so doctors and parents want to send teens to out-of-state programs.  

Connecticut has been a leader in implementing the ACA, so it is not surprising that Connecticut has established a good external review process.  The external review process is conducted by the Connecticut Department of Insurance.  Click here to go to the site.   A Connecticut ERISA benefits lawyer, familiar with Connecticut’s procedures, can be a big help in preparing an effective request for external review.

An important thing to remember about external review is the deadline is 120 days after the denial.  The regular time to appeal ERISA denials is either 60 days, or more commonly, 180 days, so make sure you, or your ERISA attorney, are aware of the difference.

Because of the external appeal process established by the ACA, at least with health insurance claim denials, the insurance company does not have the last word before you have to bring suit.