Thursday, September 17, 2009

Critics Blast Insurers for Poor Coverage of Eating Disorders

More than 11 million people in the United States have eating disorders.

And because an eating disorder can be a life-threatening condition with serious medical consequences, you'd assume that most health insurances polices would cover it. But many people living with eating disorders are falling through the cracks when it comes to health insurance, because in most cases, their treatment is not adequately covered, according to the National Eating Disorders Association.

No one knows that better than the Gomez family. Emily Gomez, 17, is fighting for her life, and her parents are fighting with their insurance company to pay for her treatment.

Emily, who lives on the Outer Banks of North Carolina, is a trained singer who dreams of performing on Broadway one day. But a few months ago, instead of travelling to the Great White Way, she travelled instead to an eating disorder clinic called Timberline Knolls in a quiet suburb of Chicago, more than 1,000 miles from home.

"You know, I'd eat a normal dinner and then afterwards just go through my pantry and anything I could find I'd eat," Emily said. "Then I'd go upstairs to my bathroom and then I'd usually end up purging."

Emily now suffers from bulimia, but when she was first diagnosed with an eating disorder about three and a half years ago, she suffered from anorexia. She tried to hide it from her family, but it soon became obvious that Emily was starving herself.

"She would eat two slices of like deli ham and a couple of pieces of lettuce," recalled her mother, Leigh Gomez. "And she would eat some carrots and some cucumbers up to the 300 calorie level. And that would be it for the whole day."

Emily started passing out in school and several times she wound up in the hospital. Her doctor said something had to be done -- and fast. "Her doctor would look at me and say, 'You have got to do something and quick. … This child is extremely sick, and if you don't do something immediately, you're going to find her dead on the floor,'" Leigh Gomez said.

A team of pediatricians said outpatient care wasn't enough. They said Emily needed long-term residential treatment.

But that treatment is expensive, ranging from $750 to $1,000 a day. Because Emily was so sick, her parents assumed the treatment would be covered by their insurer, but they were wrong.

"Each time I called, they just said I'm sorry, there's nothing we can do for you,'" Leigh Gomez said.

Serious Health Consequences of Eating Disorders

The insurer said nothing could be done, because one section of the family's Blue Cross Blue Shield North Carolina policy -- written in fine print -- caps coverage for mental illnesses at $2,000. And because eating disorders are considered a mental illness by the insurer, that is all it would pay, even though Emily's treatment cost the Gomez family more than $50,000.

"It's not covering my family," Leigh Gomez said. "It is destroying my family."

Lynn Grefe, the CEO of the National Eating Disorders Association, said eating disorders are one of the leading causes of death among young people.

According to the association, 10 percent of people with anorexia nervosa die as a result of complications from the illness. Still, victims struggle for adequate insurance coverage.

"Everything is wrong with this situation," Grefe said. "I mean, you have young people. They're usually very young women, some men, who are just fighting for their lives."

Dr. Tom Insel, director of the National Institute of Mental Health, agrees that eating disorders have dangerous medical consequences.

"In the case of anorexia nervosa, you've got an illness with very severe disability [that] frequently ends up with a long-term hospitalization and high mortality" Insel said. "So for women between the ages of 15 and 24, there's about a 12-fold increase in mortality."

"Good Morning America" talked to the medical director of the Gomez's insurer, Dr. John Bradley.

He acknowledged that while the insurance company won't pay for the treatment of a child like Emily Gomez, it would cover complications that result from an eating disorder, such as a heart condition. He said that policy "absolutely" makes sense.

"This is true for depression, if someone attempts to commit suicide and they end up in the hospital ... we cover that," Bradley said.

When asked if he believes the coverage for eating disorders is inadequate, Bradley said, "I think the coverage of a lot of conditions is inadequate."

"The financial situation that this family finds themselves in is in no small part due to the cost of the care that was delivered," he said.

Hope for Daughter's 'Health and Well-Being'

Emily Gomez is back home now. Her family just submitted a new $20,000 claim for her recent stay at Timberline Knolls, which was also denied. So to pay for Emily's treatment, her family had to do something drastic.

"Well it's just really hard when you have to cash your child's college fund in because you can't get your insurance to help you," Leigh Gomez said.

The Gomez family has complained to the North Carolina Department of Insurance, saying its insurer failed to tell the family about treatment options for Emily when they were most needed. The Gomezes are now considering a lawsuit against their insurer for negligence, but Blue Cross Blue Shield of North Carolina says they handled the Gomez's claims properly and did in fact tell the family about their treatment options.

People suffering from eating disorders have won major settlements against their health insurers in court, after arguing in class action lawsuits that the disease is biologically based and that treatment should be adequately covered.

Forty-eight states have some form of parity laws, which force insurers to cover mental health disorders the same way they cover physical disorders, but only 25 of the states have laws that apply specifically to eating disorders, and the state parity laws don't affect all insurance plans, including the Gomez's.

However, a new bill recently introduced in the House of Representatives, called the FREED Act (Federal Response to End Eating Disorders), if it became law, would require insurers offering group health insurance to specifically cover eating disorders.

While the Gomez's insurer wouldn't pay their claims, after "GMA" called the treatment center Emily first stayed at -- Remuda Ranch -- the center offered free residential treatment to her if she ever needs it again.

Leigh Gomez still has hope for a healthy future for Emily.

"I hope she finds a peace of mind," she said. "That she lays down this burden that she has. That she finds health, well-being, and that she takes Broadway by storm."

On October 11, the National Eating Disorders Association will be holding its first New York City walk to raise awareness in Riverside Park.

Project HEAL is a not-for-profit organization that raises money for people suffering from eating disorders and cannot afford treatment. For more information on this organization CLICK HERE. And CLICK HERE to visit to find out how you can get involved in Project HEAL.

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