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Diana L. Courson

Zuckerman Spaeder Brings Action in New York Against EmblemHealth for Denial of Mental Health Coverage; Says Insurer Fails to Comply with New York Mental Health Parity Law

June 22, 2015

Zuckerman Spaeder LLP has filed a complaint with the New York Supreme Court alleging that EmblemHealth has “callously” denied insurance coverage for a 15-year old girl’s medically necessary mental healthcare. On behalf of the unnamed plaintiff (“Jane Doe”) and her mother, the firm also filed a motion for a preliminary injunction asking the Court to require Emblem to immediately provide coverage for residential treatment, stating that continued denial of care puts the girl’s life at risk.

Jane Doe suffers from a serious emotional disturbance of a child, major depression, and substance abuse. Despite “unwavering” recommendations from her healthcare providers that she be treated in a residential facility, the insurer has refused to cover such care. According to Zuckerman Spaeder partner D. Brian Hufford, the defendants – EmblemHealth, Inc., EmblemHealth Services Company LLC and Group Health Incorporated – have disregarded Timothy’s Law, a New York statute that requires insurers to provide mental health coverage for serious emotional disturbances and biologically-based mental illnesses that is equal to coverage for physical conditions. “Defendants disregard serious emotional disturbances as a coverage mandate by using such conditions and their hallmark symptoms – namely, oppositionality and defiance – as a pretext for denying benefits to at-risk minors who are not willing to comply with the insurer’s coercive insistence on psychotropic medications,” added co-counsel Meiram Bendat of Psych-Appeal, Inc.

In the complaint, filed on June 19, 2015, Mr. Hufford states: 

“In denying her care, Defendants not only violated Timothy’s Law, they also violated the terms of the health insurance plan they were charged with administering. Additionally, because Defendants have misled consumers to believe that they faithfully honor their obligations to cover mental healthcare…they also violated Section 349 of the General Business Law.”

The motion for preliminary injunction, which will be filed today, states, “If injunctive relief is not granted, Jane Doe will suffer an injury that cannot later be remedied with money damages. For Jane, who is a very sick young woman, access to a Residential Treatment Center is likely a matter of life or death.”

In 2014, following an investigation by the New York Attorney General’s Office into Emblem’s practices, the insurer agreed it would cover medically necessary residential treatment for behavioral health. Despite this, the company refused to authorize Jane Doe’s treatment and continues to ignore its legal responsibilities. Zuckerman Spaeder told the Court that, due to the defendants’ ongoing disregard for the law and misrepresentations to consumers, “there is a strong public interest” in making it clear the insurer cannot continue to deny legally justified care.

The case is being led by D. Brian Hufford and Jason S. Cowart, partners in Zuckerman Spaeder’s New York office, along with associate Ramya Kasturi, and co-counsel Meiram Bendat of Psych-Appeal, Inc.

The complaint can be found here.