Denied coverage for anorexia, family aims to change N.J. law

BY CAROL ANN CAMPBELL, Star-Ledger Staff, Friday, 10/20/2006

A Wayne mother trying to force her insurance company to cover eating disorders the same way it covers other mental illnesses has lost her last appeal and said she will now seek changes in the law.

An independent review organization has sided with Horizon Blue Cross Blue Shield of New Jersey, which declined to cover long-term anorexia treatment for Dawn Beye's 16-year-old daughter Amberly.

"This is a huge disappointment.  I think this decision is intellectually dishonest," Beye said yesterday.  She said she now will file a lawsuit against Horizon as well as push for a law that requires insurers to cover eating disorders.

New Jersey law requires insurers to cover "biologically based" mental illnesses the same way they cover physical illnesses.  But insurance companies in New Jersey generally do not consider eating disorders "biologically based" and, as a result, limit coverage to 30 inpatient days of treatment.

Horizon spokesman Thomas Rubino said he could not discuss the Beye case because of confidentiality requirements, but he said in an e-mail: "We explained what the State of New Jersey law is and that anorexia and other eating disorders are not considered biologically based mental illnesses."

Beye collected statements from top anorexia experts who said they believe the disease is biologically based.

The panel of physicians reviewing the case seemed sympathetic, but ultimately disagreed.  "These reviewers do believe that Amberly Beye's anorexia is biologically based," the letter to Beye said.  Later, the letter said, "While the physician reviewers feel that anorexia is a biologically based mental illness, there is no definitive evidence."

Anyone who exhausts their insurance company's appeals process can seek an outside review by the Independent Health Care Appeals Program, operated by the New Jersey Department of Banking and Insurance.  Beye's case was sent to an Independent Utilization Review Organization.

The names of the reviewers are not made public, but a letter to Beye said the panel included a psychiatrist on staff at two medical centers and a child and adolescent psychiatrist with a sub-specialty in eating disorders.

The decision is binding on insurance companies, though a patient can pursue a case through the court system.

In recent weeks, Beye has rallied other parents pushing for better coverage for eating disorders.  At a meeting Sunday at the Wayne Public Library, more than 40 people discussed lobbying efforts in Trenton and potential class action suits.

John and Ann Brown of Harrington Park said their daughter is recovering from anorexia but was once so ill she was rushed to the hospital for fear she would have a heart attack.  The couple paid out-of-pocket for what they believe was lifesaving treatment.

"We want insurance companies to do the right thing.  We want to see true parity for eating disorders," John Brown said.  "We wiped out a couple of retirement funds and will be paying for the rest of our lives."

Sen. Joseph Vitale (D-Middlesex) said a bill (S-807) before the Senate budget committee would mandate coverage of eating disorders, with little effect on health premiums.

Beye said her family is nearly $200,000 in debt now and may sell their home.  Others at the meeting told similar stories.

Yesterday, several reacted angrily to the decision and said their children should be treated the same as those with schizophrenia, depression or bipolar disorder.

"This just underscores the need to get legislation passed in this state which provides parity for all mental illnesses and not just those that an insurance company feels is or is not 'biologically based,'" said Susan Maccia of Verona.

"My 14-year-old daughter suffers from anorexia nervosa, and she did not choose to suffer from this brain disorder," she said.  "She would give anything to just make it go away and be able to live a normal life."

The president of the New Jersey Psychiatric Association, Joseph C. Napoli, said stigma exists against eating disorders.

"There is a bias in this society," he said.  "'You made this all up.' 'Just get over it.'" he said.

The 1999 New Jersey parity law requires insurers to cover "biologically based mental illnesses" that include, but are not limited to, schizophrenia, obsessive-compulsive disorder, psychosis, major depression and others.  It does not specifically list eating disorders.  Lobbyists for the psychiatric association will ask the governor to reinterpret the existing law.  The American Psychiatric Association, meanwhile, has concluded the biological/nonbiological distinction is not valid.

Carol Ann Campbell covers medicine.  She may be reached at ccampbell@starledger.com.