Treating anorexia: the question of insurance

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To add to the difficulty of battling my child's illness, I was forced to battle our insurance company at the same time. There was always a problem about whether this condition should be covered by mental-health benefits or medical benefits.

Restrictive anorexia is very much both a medical and mental illness. However, insurance companies see it as a mental illness.

When a child is placed in the hospital, however, it is for medical reasons — the slowed heart rate and the drops in blood pressure and the complicated re-feeding that is necessary.

In our case, mental-health benefits covered her in the Kartini Clinic Day Treatment Unit (DTU), and the medical benefits covered the medically necessary tests she was given. When my daughter was in the hospital bed, the medical benefits paid.

I was forced to spend many hours on the phone in the Ronald McDonald House giving specific information to help the insurance company sort out who would pay the bills. The insurance company also required the doctors at the Kartini Clinic to call them with weekly reports of her condition before making any decisions about paying.

The most difficult battle came when her medical insurance denied her visits to the Kartini Clinic after leaving the DTU. They said: "Anorexia is not a medical condition."

I followed all the rules of resubmitting claims and when denied again I had to submit the claims to the "board."

After the decision of the board was to also deny coverage, I was told I had to write a letter within a month to open an appeal. I was then given a date and time to appear in their Portland Office in front of the "appeals committee."

With the help of a friend, I was able to write a precise explanation of why my daughter's condition (anorexia) should be considered medical, and why it was in their best interests to cover her visits to the Kartini Clinic.

I also arranged for her doctor at the Kartini Clinic to call with her recommendation for my daughter's treatment.
 
After fighting three months for medical coverage, I finally won this last appeal. Our medical insurance was required to pay all previously denied visits and all following visits for the next year. Then they again began to deny claims. I continued to fight the denials with telephone calls and e-mails.

I thought I'd have to again go before the "appeals committee." However, the case manager reported to me that the claims would be paid in good faith on their part.

However, a month has passed and they have not yet paid. Yesterday I called and was told the process is taking longer than expected.

— Therese S. Waterhous, special to The Seattle Times

In Washington state

All the major insurance companies operating in Washington consider anorexia and other eating disorders to be behavioral-health issues and covered treatment under mental-health benefits provisions, if they exist in a particular contract.

"The American Psychiatric Association classifies eating disorders as mental-health conditions," said Regence BlueShield spokeswoman Jodi Coffey. Treatment of medical problems associated with eating disorders, such as digestive or coronary conditions, would be covered under a member's medical benefits, she said. That was true of other insurers as well.

It's quite rare, perhaps one to two cases per year, that someone is hospitalized for medical problems related to an eating disorder, said Group Health Cooperative's spokeswoman, Laura Query.

Typically, plans offer less coverage, both inpatient and outpatient, for mental-health treatment, although there is wide variation in plans.

Some plans do not cover mental-health treatment at all. For example, none of the individual plans sold by Premera have mental-health benefits, said spokesman Chris Jarvis.

When someone covered by Premera is diagnosed with an eating disorder, the insurer assigns a case manager to offer assistance, even if the plan doesn't cover mental health, he said. In that case, the case manager would refer patients to resources in the community, he said. "We want to do everything we can to help them find treatment."

Outpatient treatment after hospitalization would be covered under mental-health benefits, the insurers said.

— Carol Ostrom, Seattle Times staff reporter