83-pound Sacramento-Area Woman Denied Life-Saving Treatment
Kantor & Kantor, LLP, is appealing to the California Department of Insurance on behalf of Kimberly Shepard, a young wife and mother in danger of losing her life from the debilitating effects of Anorexia Nervosa because her health insurer United HealthCare Insurance Company declined her claim for benefits to pay for residential treatment.
The appeal requests that the Department of Insurance order United Healthcare to reverse their denial of benefits. Earlier this month, the U.S. District Court for the Northern District of California denied Shepard’s temporary restraining order to enjoin United HealthCare from continuing to withhold benefits.
Shepard sought treatment in February at Monte Nido residential treatment center in Malibu, CA a preferred provider under Shepard’s health policy. Although Shepard’s condition more than met the policy’s conditions for residential treatment, United HealthCare denied her claim. As a result, Shepard exhausted her family’s financial resources to pay for treatment. By April 1, Shepard could not longer afford treatment, even though her doctors agreed she had not recovered enough to make appropriate life-sustaining decisions regarding food. Presently, Shepard’s prognosis for recovery is poor if she is not able to continue residential treatment.
“United Healthcare is obligated to pay benefits that will save Ms. Shepard’s life,” said Shepard’s lawyer Lisa Kantor. “The family is out of money. Her husband, an Elk Grove firefighter, and her 3-year-old son, are desperate to ensure that this loving wife and mother recover and return to her home. We are urging United HealthCare to do the right thing and pay for her treatment.”
Under her policy, Shepard must meet only one of the following three requirements to qualify for residential treatment at an eating disorder facility: severe impairment in psychosocial function due to a behavioral health condition; signs of a behavior health condition that clearly demonstrate a need for 24-hour supervision; or a deteriorating health condition likely to require inpatient care. Shepard’s psychiatrist Dr. Cindy Murrer and the attending physician at Monte Nido, Dr. Gary Schneider, both testified that she met all three requirements.
United HealthCare’s “peer review” report by a company doctor who never examined Shepard, conflicted with her treating physicians’ diagnosis, opined that even though Shepard weighed less than 85 pounds and was unable to care for herself, she “does not meet medical necessity criteria for admission to residential mental health treatment.” The report found that Shepard “is not showing any significant physical abnormalities,” had only “some suicidal ideation,” and “had not participated in appropriate eating disorder treatment at lower levels of care.”
“Those findings are untrue and inappropriate bases for denial of coverage,” says Kantor. “United HealthCare’s blatant disregard for its policyholder’s welfare is a flagrant breach of the terms of its policy.”
Shepard has also filed a complaint in the Northern District court against United HealthCare for damages for breach of contract and breach of the covenant of good faith and fair dealing.