Kantor & Kantor Announces North Cypress Medical Center Must Reimburse Benefits for Mental Health Treatment

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Fifth Circuit Court of Appeals Reverses Decision After Finding No proof That Prior Authorization Was Needed For Mental Health Treatment

“Today, the Fifth Circuit took the right step to enforce the statute in the manner to protect insureds as it was originally intended.”

Kantor & Kantor, LLP announced today that the Fifth Circuit Court of Appeals ruled in favor of the firm’s client Rebecca Hamsher, deciding that in accordance with ERISA (Employee Retirement Income Security Act), North Cypress Medical Center must reimburse benefits for Hamsher’s residential treatment for bulimia, depression and other mental health problems.

According to the U.S. Court of Appeals decision, Hamsher, a nurse employed by North Cypress Medical Center, was admitted to Timberline Knolls Residential Treatment Center in Illinois in May 2011, where she was treated for various mental disorders. North Cypress refused to pay for this treatment, as it concluded that she had neither asked for nor received prior-authorization for “hospital expenses incurred at hospitals other than North Cypress.” In January 2012, Hamsher internally appealed this decision and North Cypress again denied her claim – stating that the evidence in the administrative record showed that she failed to obtain the necessary prior-authorization for hospitalization. At this point, Hamsher filed suit against North Cypress in an attempt to recover the ERISA benefits to which she was entitled.

The appeals court found that North Cypress Medical Center failed to show that Hamsher received her care in a setting that qualified as a “hospital” under its health insurance plan. Because prior authorization is only required for care in a hospital setting, Hamsher is entitled to coverage.

“Unfortunately, too often courts apply ERISA to afford unreasonable deference to the decisions of financially motivated insurers and plan administrators," said Lisa Kantor, of Kantor & Kantor, LLP who represents Hamsher. “Today, the Fifth Circuit took the right step to enforce the statute in the manner to protect insureds as it was originally intended.”

About Kantor & Kantor, LLP

Kantor & Kantor is the largest law firm in the country exclusively representing plaintiffs who have been denied insurance benefits from life, health disability and long-term care policies. The firm has extensive experience with the complex appeals process and federal court litigation of ERISA matters. For more information, log on to our website, call (800) 446-7529, or follow Kantor & Kantor at http://www.californiainsurancelawyerblog.com.

For more information about Lisa Kantor and Eating Disorder Legal Assistance, please visit our website and our Eating Disorder blog, or follow us on Facebook.

Contact: Rachel Teicher
Kantor & Kantor, LLP
818-886-2525
rteicher(at)kantorlaw(dot)net

Rebecca Hamsher v. North Cypress Medical Center Operating Company, LimitedAppeal from the United States District Court for the Southern District of Texas USDC No. 4:13-CV-1401

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Rachel Teicher

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