Facts
- Mount Sinai Hospital provided inpatient treatment to Jane Zorek for approximately three weeks under a physician-prescribed, non-caloric weight-reduction program (the “Duncan Regime”).
- Zorek was significantly overweight and had experienced obesity-related medical complications treated by her physician.
- The Duncan Regime involved consuming no calories (only water, vitamins, and minerals) and was described as potentially dangerous, warranting close medical observation.
- During the admission, Zorek lost about 17½ pounds without adverse incident.
- Mount Sinai billed for the hospitalization; Warren Zorek (her husband) did not pay in full and sought reimbursement under his family Blue Cross contract issued by Associated Hospital Service of New York (AHS).
- The policy covered hospital services “necessary for the proper treatment” of the member and excluded “convalescent or sanitarium type care,” “rest,” and similar custodial stays; obesity was not listed among the policy’s enumerated exclusions.
- AHS denied coverage, asserting that obesity was not a covered “disease” and that the admission was unnecessary and functionally convalescent/rest care.
- Mount Sinai sued Warren Zorek for the unpaid charges; Zorek impleaded AHS in a third-party action seeking coverage.
Issues
- Whether obesity constitutes a covered medical condition under a hospital service contract that does not expressly exclude obesity.
- Whether inpatient hospitalization for a medically supervised, high-risk weight-reduction regimen was “necessary for the proper treatment,” or instead excluded as convalescent/sanitarium-type care or “rest.”
Decision
- The court found coverage and rejected AHS’s denial defenses.
- The court held that obesity is a medical problem for purposes of coverage under the contract.
- The court held that hospitalization was medically necessary given the risks of the prescribed regimen and was not convalescent/sanitarium-type care or mere rest.
- Judgment effectively required AHS to reimburse the covered hospital charges, determining responsibility for payment of Mount Sinai’s bill.
Legal Principles
- A condition may be treated as a covered medical problem where the policy does not clearly exclude it and the evidence shows health-related complications and medical treatment needs.
- Hospitalization is “necessary for proper treatment” when, based on medical evidence, inpatient monitoring is required due to the risks of the prescribed therapy.
- Policy exclusions, including exclusions for convalescent/sanitarium-type care or “rest,” are construed narrowly against the insurer; ambiguity is resolved in favor of coverage.
- The omission of a condition from a policy’s enumerated exclusions supports an inference that the condition was not intended to be excluded.
Conclusion
The court required coverage for inpatient treatment of obesity where the physician-prescribed regimen posed sufficient medical risk to make hospitalization necessary, and where the insurer’s reliance on convalescent/rest-care exclusions could not overcome the policy’s coverage language and the absence of any express exclusion for obesity.