Anthem Blue Cross May Wrongfully Deny Coverage for Eating Disorders

Anthem Blue Cross, the health insurance provider, was accused in a proposed class action on Monday of denying coverage for eating disorders in violation of California’s mental health laws.

The suit, filed in state court, alleges that plaintiff Shelby Oppel has been treated for bulimia nervosa and had her coverage artificially capped, despite being a policyholder. Oppel alleges that Anthem Blue Cross caps coverage for the eating disorders bulimia and anorexia to meet preset cost goals – and that this violates the state’s Mental Health Parity Act, a law that requires all necessary treatment for both conditions to be covered by insurers.

Proposed a class action for denying coverage for eating disorders.

The company allegedly uses its guidelines as explanation for coverage caps, despite the mandate in the state’s laws that all treatments be authorized and covered. The disorders, characterized by a fear of gaining weight and an often distorted body image, have a mortality rate of more than twenty percent and can lead to other severe health problems, the complaint says. These health problems include infertility, heart failure and kidney failure. California’s Mental Health Parity Act therefore labels the disorders as ‘serious’ and requires health insurers to meet the costs for all necessary treatment.

Oppel claims that when she sought coverage for a course recommended specifically by psychiatric hospital BHC Alhambra after she was admitted for acute inpatient treatment, Anthem Cross refused. The course – for six-month inpatient, six-month outpatient treatment – would not be covered, the insurer said, claiming that only six days of acute treatment were necessary. Oppel also claims that the denial was robosigned by a physician who did not know her individual case details. This denial was then peer-reviewed by a doctor lacking the experience or credentials to treat eating disorders, Oppel also claims.

Anthem Blue Cross is accused in the complaint of following outdated references in order to form coverage plans and failing to follow American Psychiatric Association standards for the recognition of medical needs for eating disorders. The complaint also accuses the peer-reviewed denial system of being flawed, utilizing robosigning and doctors who are ethically compromised and likely to follow company guidelines rather than evaluate cases independently. As such, Oppel is seeking to represent a class of California Anthem individual preferred provider organization plan holders who have been denied coverage and benefits for eating disorders. She is also seeking an injunction requiring the company to amend its guidelines for eating disorders, as well as costs and damages. The case is being brought under California’s mental health laws as well as the Unruh Civil Rights Act, an act that bans discrimination against medical conditions or disabilities.