Mansell, Engel & Cole

Health insurer sued for abrupt about-face re treatment denial

“We have … determined that the treatment is medically necessary.”

Those were precisely the words that a woman recommended for entry into an in-house program for severe eating disorders was waiting to hear from her health insurance company. Following Wellmark’s approval of the precertification request, the policyholder formally entered a well-established treatment center to deal with her longstanding bulimia nervosa condition.

She completed the Emily Program’s treatment regimen about a month later. Shortly after that, she received a surprising communication from Wellmark.

And that was this: An official insurance denial of her claim, coupled with a payment demand of $51,000.

That was understandably shocking news, but, as noted in an in-depth article probing the details, far from an anomaly. In fact, Wellmark has acted similarly in cases involving other patients seeking eating disorder-linked treatments at the Minnesota-based facility. That is, the insurer has approved precertification requests only to deny coverage following treatment completion.

In noting that “pattern of abrupt denials,” the above media report also underscores the surprise and alarm of Emily Program officials. They reportedly “had never seen an insurer pre-authorize and then abandon the patient after treatment was completed.” A program principal called Wellmark’s repeated behavior “unique in our experience.”

The insurer’s conduct will now be further scrutinized in a federal court, following the recent filing of a lawsuit by the woman presented the $51,000 bill. Her complaint alleges that Wellmark acted in bad faith and breached its contractual duties owed to the plaintiff.

The lawsuit demands both compensatory and punitive damages against the insurer.

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