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Court Affirms Denial of Eating Disorder Coverage 

Hodgson Russ Employee Benefits Newsletter
April 30, 2019

The U.S. Court of Appeals for the Eleventh Circuit affirmed a district court’s decision to uphold a plan’s denial of coverage for eating disorder hospitalization. In this case, the plaintiff suffers from anorexia and over many years has tried different types of treatments, including hospitalization. In 2010, she entered a “partial hospitalization” program. In 2011, however, the treatment facility’s medical director found that the plaintiff’s condition improved and that “partial hospitalization” was no longer medically necessary. The plaintiff challenged the decision through two levels of internal appeal and an external appeal. The internal appeals were reviewed by doctors not previously familiar with the plaintiff’s case and the external appeal was assigned to an independent reviewer.  Each of the reviewers upheld the plan’s decision to deny coverage based on the “partial hospitalization not meeting the plan’s definition of medical necessity.”  This case highlights the importance of a plan having and following a claims procedure providing for a full and fair review of claims based on the terms of the plan.  Alexandria H. v. Oxford Health Ins., Inc. (11th Cir. 2019).

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