Eating Disorders a New Front in Insurance Fight
Jim Wilson/The New York Times

People with eating disorders like anorexia have opened up a new battleground in the insurance wars, testing the boundaries of laws mandating equivalent coverage for mental illnesses.

Through claims and court cases, those with severe cases of anorexia or bulimia are fighting insurers to pay for stays in residential treatment centers, arguing that the centers offer around-the-clock monitoring so that patients do not forgo eating or purge their meals.

But in the last few years, some insurance companies have re-emphasized that they do not cover residential treatment for eating disorders or other mental or emotional conditions. The insurers consider residential treatments not only costly — sometimes reaching more than $1,000 a day — but unproven and more akin to education than to medicine. Even some doctors who treat eating disorders concede there are few studies proving that residential care is effective, although they believe it has value.

“We’ve seen an increase in denials,” said Kathleen MacDonald, education and prevention coordinator for the Gail R. Schoenbach FREED Foundation, an advocacy group for those with eating disorders. “Now, I go to bed every night and I can’t answer all the e-mails I get. It’s heartbreaking.”

Both sides are closely watching the consequences of a major decision by the United States Court of Appeals for the Ninth Circuit, which ruled in August that insurers in California must pay for residential treatment for eating disorders and other serious mental illnesses under the state’s mental health parity law.

In the last decade or so, many states enacted similar laws, and, in 2008, so did the federal government. The laws generally require that coverage for mental and behavioral disorders be equivalent to that for physical ailments like diabetes or a broken bone.

But equivalence, or parity, can be tricky to define, and the appeals court ruling is one of the first by a high federal court to interpret the concept.

Blue Shield of California, the defendant in the lawsuit, is already seeking to have the case reheard, arguing that the decision could force insurers to pay for unlimited amounts of treatment, raising insurance costs.

While the ruling applies only to California’s law, some experts think it will influence courts, state agencies and insurers elsewhere.

“You’ll see it bleed over,” said Scott Petersen, a lawyer in Salt Lake City who often represents insurance companies in parity cases.

In New Jersey, Aetna, Horizon and AmeriHealth have agreed to end limits on the number of days of residential treatment they will cover for eating disorders, according to Bruce Nagel, a lawyer who sued the insurers under the state’s parity law.

The Parity Implementation Coalition, a group monitoring the federal parity law, has filed about 150 complaints about possible violations, according to Dr. Henry Harbin, a psychiatrist and adviser to the group. Some cases involve denial for residential treatment for substance abuse or mental illnesses by plans offered by companies like Wal-Mart and Coca-Cola Bottling.

An estimated 11 million Americans, mostly young women, suffer from eating disorders, the most serious being anorexia nervosa, in which people starve themselves, and bulimia nervosa, in which they engage in binge eating followed by purging. These disorders, particularly anorexia, have the highest fatality rate of any psychiatric disorder.

The advocates for those with eating disorders, who often cooperate or get financing from residential treatment centers, estimate there are about 75 such facilities for those specific illnesses, and many others for substance abuse and for emotionally or psychologically disturbed children.

Sam Menaged, founder and president of the Renfrew Center, which is based in Philadelphia and is one of the oldest and largest residential treatment centers for eating disorders, said only 60 percent of insurers covered the therapy and that hundreds of people were turned away from Renfrew each year.