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Court rules insurer must pay for teen gynecomastia

Article-Court rules insurer must pay for teen gynecomastia

New York — The New York State Supreme Court’s Appellate Division has upheld two lower-court rulings requiring an insurer that had refused to pay for a teenage boy’s breast-reduction surgery because it was cosmetic to reimburse his father for the operation, reports the Associated Press.

The Supreme Court’s decision thus directs Group Health Inc. (GHI) to pay for the surgery, calling it “medically necessary” in order for the boy to lead a normal life.

In 2004, the boy’s father sued GHI because the insurer refused to pay for the boy’s breast-reduction surgery. GHI felt the surgery was cosmetic and not medically necessary. A Manhattan Civil Court ordered GHI to pay $5,000 to the father, who had already paid $7,500 for his son’s surgery.

In March 2006, the state Supreme Court’s Appellate Term affirmed the Manhattan Court’s ruling, and following an appeal by GHI, the State Supreme Court’s Appellate Division unanimously upheld the Appellate Term, rejecting GHI’s argument that the plaintiff’s claim of emotional distress was not supported by a mental-health professional.

“The condition suffered by plaintiff's son was characterized by plaintiff’s medical providers as a ‘deformity’ and, particularly in the case of a 17-year-old male, clearly a devastating condition with ‘psychosocial’ consequences,” the Appellate Division judges wrote, adding that it was “absurd to deny coverage on the grounds that plaintiff’s son did not provide support from a mental-health professional, particularly where the external review decision itself acknowledges that the patient suffers ‘depression’ and ‘emotional distress’ from this condition."

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