Suit Challenges Way Insurance Firms Divide Physical, Mental Illnesses

For two years, Jim’s 13-year-old son was lost amid the chaotic madness of manic-depressive illness. That was Jim’s greatest loss, but not his only one.

The self-employed insurance agent, who asked that his last name not be used, lost his savings, nearly lost his business and had to turn to friends for loans--all because he lost insurance coverage for his son’s illness.

More than $90,000 in medical bills piled up because his insurance company, Blue Cross & Blue Shield of Illinois, said the boy’s illness was mental rather than physical, and thus subject to lesser benefits.

Now Jim’s hardships, and his bitterness toward Blue Cross, have become his cause. He has joined a class-action lawsuit against several insurers, challenging the way illness is classified and contending that manic-depressive illness is indeed a physical problem.

“I don’t want anybody to have to go through what me and my wife did,” the 44-year-old resident of a Chicago suburb said.

“Where I’m at today is just where I was when me and my wife got married--starting over. Everything we had done to assure our golden years is gone. We had no savings. All investments were sold. We had nothing.”

The federal suit filed 18 months ago against Blue Cross, Guardian Life Insurance Co. and Travelers Insurance Co. of Illinois contends that insurers have created arbitrary categories for “mental” and “physical” illnesses to control costs.

The plaintiffs also say that manic-depressive illness is a physical illness caused by an inherited genetic disorder that triggers a chemical imbalance in the brain.

“People who sign up for insurance don’t usually know what they’re getting until something happens,” said attorney Robert Gettleman, representing the plaintiffs. “They feel: ‘I am covered if something happens to me that I cannot do something about.’ ”

Even Jim, who sells insurance, did not read the policy closely enough to know there was a crucial difference in mental health coverage.

A 1988 federal Bureau of Labor Statistics study found that only 27% of those covered by health insurance had inpatient mental health benefits that were as good as benefits for other illnesses. That was down from 54% in 1980.

But insurance companies caution that a reclassification would place an undue strain on the already-spiraling price of health insurance.

The Employee Benefit Research Institute says mental health care costs have climbed even faster than other types of health care costs--27% between 1987 and 1988 alone, to an average of $207 per employee in 1988.

Insurance companies contend that the cause of manic-depressive illness still is undecided. And in any case, they say, insurers always have classified illnesses by symptoms rather than cause--and people suffering from manic-depressive illness clearly show signs of a “mental illness.”

Manic-depressive illness, also called bipolar disorder, plagues almost 2 million Americans, according to estimates by the National Depressive and Manic Depressive Assn., which is a party to the lawsuit.

It is an illness of opposites--a mood problem characterized by episodes of serious mania and depression.

Symptoms during periods of mania include excessive euphoria and unrealistic beliefs in one’s abilities. Depressive episodes are sometimes marked by feelings of hopelessness, sleep disturbances and weight loss.

In many cases, bipolar disorder can be successfully treated with a combination of drugs and therapy. But some victims undergo lengthy hospital stays.

The disorder has been linked to faulty genes but the precise genes have not been determined, said Dr. Jan Fawcett, chairman of psychiatry at Rush Presbyterian St. Lukes Medical Center in Chicago, and an expert on the illness.

Victims of manic-depressive illness frequently--as in the case of Jim’s son--lead perfectly normal lives until adolescence or early adulthood, when the illness erupts.

Jim’s son first showed signs of the disorder in junior high school, when his moods began swinging wildly. He became abusive to his parents; his behavior was sometimes violent.

His parents first suspected that he was using drugs, then scheduled months of psychiatric consultations that culminated in a costly hospital stay.

The family’s insurance policy, which had a $1-million lifetime cap for physical illnesses, had a $50,000 cap for mental illnesses, which soon was exhausted.

“About everything you could think of that could go wrong went wrong,” Jim said. “I put it all on the line. I said: ‘Let the business go; I’ve got to do something about this kid. He’s too young to have this kind of problem.’ ”

Two years and two hospitalizations later, his son’s problem was finally diagnosed as bipolar disorder and he was placed on lithium, commonly used to combat the illness.

“From that point on, our lives changed,” Jim said.

Although some medical bills remain, his own insurance business is restored and his family life is more routine than it has been in years.

His son, now 20, spends about $140 a month on medication. He lives at home and works as a mental health technician in a state hospital, a career he chose because of the difficulties he endured, Jim said.

He is slightly slower--mentally and physically--than he once was. But “if you did not know the medication was there, you would not know that anything is wrong with him,” Jim said.

The lawsuit is awaiting a judge’s decision on whether the class should be certified.

In addition to the question of how manic-depressive illness is classified, the suit also contends that insurance policies do not clearly define mental illness.

“Two of the policies have no definition of mental illness at all,” Gettleman said. The third policy’s definition is so broad, it is virtually useless, he said.

The insurance companies disagree.

In the contract, “they expressly used the words ‘mental and nervous disorders’ and have somewhat limited coverage with regard to those disorders,” said attorney Robert Johnson, representing Travelers.

He said the medical community has continually classified manic-depressive illness as a mental and nervous disorder.

“The terms of our contract are very clear,” said Chris Kronberg, representing Blue Cross. “We’re not bad guys because we don’t cover manic-depressive illness.”

A Missouri man lost a similar case on appeal against Lincoln National Life Insurance Co. of Indiana for providing less coverage for his son’s manic-depressive illness. His case, filed in St. Louis, was appealed to the U.S. Supreme Court, which refused to hear it.

Attorneys for both sides agree that the Chicago lawsuit could take years to resolve.

Jim said he is prepared for a long battle.

“You know what we’ve been through and the strain that this brings on a family,” Jim said. “If we can stop somebody else from having to do this, then it’s worth joining.”