Suit Seeking Health Coverage for Eating Disorders Can Proceed

A lawsuit challenging Aetna's failure to provide coverage for eating disorders can go forward, a New Jersey federal judge has ruled.

Judge Faith S. Hochberg of the U.S. District Court for the District of New Jersey denied Aetna's motion to dismiss based on the plaintiffs' failure to exhaust its internal appeals process before filing suit.

Her decision here likely will allow two related suits pending before her to proceed as well.

The plaintiffs in those cases filed similar claims against Blue Cross Blue Shield in New Jersey, and the insurer raised similar arguments for dismissal.

The plaintiffs in all three suits assert that eating disorders are biologically based mental illnesses that require a higher level of insurance coverage than the insurers currently provide.

Aetna classifies eating disorders as non-biologically based mental illnesses, or BBMIs.[0][0]

New Jersey residents Frank DeVito and Jeff Meiskin filed suit in January 2007, saying Aetna denied coverage for their daughters for treatment it deemed not medically necessary and stopped paying benefits after the non-BBMI coverage limit was reached.

Aetna provides 30 days of inpatient benefits and 20 outpatient visits a year for non-BBMIs, while biologically based mental illnesses receive broader coverage, the suit says.

New Jersey law does not list eating disorders such as anorexia and bulimia as biologically based mental illnesses.

However, a bill pending before state legislators would add such disorders to the state's Mental Health Parity Law, which regulates health insurance coverage.

The change would classify eating disorders as BBMIs and therefore require insurers to provide more coverage.

DeVito and Meiskin claim that Aetna improperly classified eating disorders and breached its contractual obligation by denying coverage their daughters were entitled to.

Judge Hochberg rejected Aetna's request to abstain from ruling on the suit to await the outcome of the bill pending in the state Assembly.

The judge said the measure would not affect her decision because the suit concerns past coverage, and any new legislation would not be retroactive.

She also noted that the case concerns the language in the plaintiffs' contracts with Aetna.

Further, the insurer's internal appeals process for claims disputes may not adequately address the plaintiffs' issues, Judge Hochberg said, explaining her decision to deny dismissal.

But the judge said they are entitled to conduct discovery to support their claim that the insurer's appeals process is insufficient, and it would be premature to rule on the case's merits before discovery.

Judge Hochberg did dismiss the plaintiffs' claim for punitive damages brought under the Mental Health Parity Law.

She said the claim fell under the federal Employee Retirement Income Security Act, which preempts the state law.

ERISA does not provide for compensatory or punitive damages.

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