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Allan Schwartz, Ph.D.Allan Schwartz, Ph.D.
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Eating Disorders and Health Insurance

Allan Schwartz, LCSW, Ph.D. Updated: Aug 16th 2011

Eating Disorders and Health Insurance Is it a mental health condition or is it a medical health issue?

Hypothetical Case:


This is a true story. It's about families all over the nation who have a loved one suffering from an eating disorder or any chronic illless. So, do not be surprised if you recognize yourself or someone you know.  It is about all of us:

"She is a young woman who has struggled with Anorexia Nervosa since she was 17 years old. Her family got treatment for her but the disease persisted well into her adult life.

Now, married, she experienced a serious relapse with the result that her weight dropped dangerously low. Her husband, alert to the danger his wife was in, gains her cooperation in looking for the best treatment possible. His health insurnce promises to cover the costs of treatment. She enters an intensive outpatient program, also known as a partial hospitalization.

She attended the program 7 days per week during which she participated in groups, saw a psychotherapist, nutritionist and was in family therapy involving not only her husband, but, her parents and siblings, as well. She was beginnig to improve when, suddenly, she was informed, by the insurance company, that they were refusing to reimburse the eating disorder center that was treating her. 

The insurance agents alternated between telling her that this was not a psychiatric problem and needs to be addressed by the medical department. The medical department refused to do anything, claiming that she must speak with the psychiatric branch of the company. In the mean time, the bill goes unpaid and she is forced to stop treatment because she has accumulated a huge bill that she and the center believed was either paying or about to pay.

Left without treatment, she is losing weight again and is an a vulnerable and dangerous situation.

Sound familiar?"

Seemingly, this is a problem and question that insurance companies cannot or will not resolve. Are eating disorders psychiatric or medical and, therefore, how should they cover the bills. As a result of this confusion, many people diagnosed with ED fall into this crack in coverage and are left in limbo.

What I find vexing and troubling is that, in situations like the hypothetical one above, are health insurance companies truly confused or have they found a loop whole, providing them a way to avoid paying for coverage of this and other types of illnesses?

Anorexia, bulimia, binge eating disorder and others are chronic disorders and illnesses are deadly if left untreated. Much like cancer and diabetes they do not go away. Because of the chronicity of these illnesses, they need ongoing treatment. In the most serious of cases patients need either intensive hospital in patient help or the equivalent outpatient treatment also known as partial hospitalization.

Any type of hospitalization, full or day, is beyond the ability of most people to pay without insurance. The bills can run into the hundreds of thousands of dollars. The problem is clear. If these people do not receive medical help they can die. Looking at the statistics, it is horrifying to many how many lives are lost annually to these diseases, many of them teenagers as young as 13 and 14.

If you have a loved one with an eating disorder or know people who have, find out how you can help. Go to this website:

http://www.eatingdisorderscoalition.org

The Eating Disorders Coalition is working to give patients and their families and friends a voice so that they can be heard in Washington D.C.

Allan N. Schwartz, PhD

Allan Schwartz, LCSW, Ph.D.

Readers who live in the Boulder, Colorado metro area, or in Southwest Florida may contact Dr. Schwartz for face-to-face consultation. He is also available for psychotherapy through Skype video for those who are not in Florida or Colorado. He can be reached via email at dransphd@aol.com for details.

    Reader Comments
    Discuss this issue below or in our forums.

    Health insurance in the US - - Aug 17th 2011

    The correct term is "loophole," as opposed to "loop whole"

    Health insurance is a for-profit operation. God help you if you're sick. They will use this weakness against you to get out of providing the coverage that previously they were only too happy to take your money for in the past. People cannot sustain a big legal battle when they fall seriously ill and a profit motivated firm will exploit this fact to increase their own profits. Even if you get a clearly medical disease such as cancer, you will be under increased scrutiny for recission (http://tauntermedia.com/2009/07/28/unconscionable-math/). If they can play hot potato with a behavioral issue until the customer is too sick to fight them anymore, of course they will.

    There is a common practice that anything an insurance rep tells you over the phone is subject to revision after the claim is submitted. Just because an agent tells you a given treatment is covered, you cannot know the claim will not be denied unless you have your own lawyer on retainer or until the claim is processed.

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