## 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

1. Whether obesity constitutes a covered medical condition under a hospital service contract that does not expressly exclude obesity.
2. 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.


Mount Sinai Hosp. v. Zorek, 50 Misc. 2d 1037, 271 N.Y.S.2d 1012 (N.Y.C. Civ. Ct. 1966)