August 21, 2014
by Kathleen MacDonald, Policy & Communications Director, Eating Disorders Coalition
The +Eating Disorders Coalition offers huge congratulations to +Kantor & Kantor, LLP for their most recent success in fighting back against an insurance company's wrongful denial of benefits for an eating disordered patient, Ms. Jones*.
On January 7, 2014, Kantor & Kantor attorneys Elizabeth Green, Lisa Kantor and Peter Sessions appealed to the United States Court of Appeals for the Ninth Circuit Court on behalf of Pacific Shores Hospital ("PSH"). On August 20, 2014, Judge William A. Fletcher issued his opinion that reversed the original district court's judgment, a baffling judgment that sided with United Behavioral Health; Wells Fargo & Company Health Plan ("UBH"). For Jones' treatment, Judge Fletcher opined, "We conclude that UBH abused its discretion in refusing to pay for the these days of treatment."
Judge Fletcher went on to boldly call out UBH's Drs. Barnard, Center and Zucker for their several wrongdoings in and mishandling of the patient's (Ms. Jones) benefits for treatment, stating, "Fiduciaries must discharge their duties "with the care, skill, prudence, and diligence under the circumstances then prevailing that a prudent man acting in a like capacity and familiar with such matter would use in the conduct of an enterprise of a like character and with like aims." "UBH fell far short of fulfilling its fiduciary duty to Jones. Dr. Zucker, UBH's primary decisionmaker, made a number of critical factual errors. Dr. Center, as an ostensibly independent evaluator, made additional critical factual errors. Dr. Barnard, UBH's final decisionmaker, stated that he arrived at his decision to deny benefits "after fully investigating the substance of the appeal." He then rubber-stamped Dr. Center's conclusions. There was a striking lack of care by Drs. Zucker Center and Barnard."
I had the privilege and honor of watching Elizabeth Green argue this case at the district court level. Elizabeth's thorough knowledge of the case, and of the patient's suffering and the complexity of her illnesses, is a standard that every insurance company and insurance company decisionmaker would be wise to measure themselves against, and emulate.
The persistence of Kantor & Kantor and the wisdom of the Ninth Circuit Court proves once again that insurance companies cannot continue to wrongfully deny benefits and expect to get away with it, sans consequence. And I also believe that this opinion proves that good always trumps evil --even if it takes a little bit of time for good to prevail.
The entire opinion** can be read here: http://cdn.ca9.uscourts.gov/datastore/opinions/2014/08/20/12-55210.pdf
*The patient's name has been changed to protect her privacy
**I urge caution that if you are someone who is "triggered' by behaviors and numbers such as weight or BMI, you might not want to read the opinion as Ms. Jones' case is described in detail.