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Parity at work: CIGNA admits wrongful denial of behavioral health claims in New York

January 23, 2014
by Dennis Grantham, Editor-in-Chief
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Insurer allowed unlimited nutritional counseling for diabetics, but denied it to anorexia patient

After an investigation by the New York Attorney General’s office (OAG) uncovered the wrongful denial of hundreds of claims for nutritional counseling for patients with eating disorders, CIGNA Corporation recently agreed to reprocess and pay those claims.

Pursuant to a settlement with the OAG, the company agrees to comply with Timothy’s Law, a state law enacted in 2006 and named for a 13-year-old Schenectady boy who committed suicide after an insurance company denied ongoing coverage for treatment of serious mental health issues, including hospitalizations.  That law mandates that New York group health plans provide “broad-based coverage for the diagnosis and treatment of mental, nervous or emotional disorders or ailments … at least equal to the coverage provided for other health conditions.”

The New York law is similar to the federal Mental Health Parity and Addiction Equity Act, which was passed in 2008.

Under terms of the settlement, Cigna has agreed to eliminate its three-visit cap for nutrition counseling associated with mental health conditions and to reprocess and pay members whose claims were denied due to the limit, totaling approximately $33,000. Cigna will also conduct in-service training for its claim and clinical review staff regarding the removal of visit limits for nutritional counseling prescribed for mental health disorders. Under the settlement, Cigna will also pay $23,000 to the OAG as a civil penalty.

This investigation and settlement are notable for parity advocates because OAG investigators based their findings on a direct comparison between CIGNA’s benefits for a medical condition – diabetes – and a mental health condition – eating disorders.  For years, CIGNA’s diabetic patients were allowed unlimited nutritional counseling sessions in a calendar year while eating disorder patients – including the young anorexia nervosa patient whose parents first complained to the OAG – were limited to just three visits per calendar year.  

Though federal parity law was not applied in this case, the difference in visits allowed for patients with medical conditions versus visits allowed for patients with mental health conditions offers an example of a “quantitative treatment limit” that would also be disallowed under the federal Mental Health Parity and Addiction Equity Act.

 

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