NEW YORK – An insurer that refused to pay for a teenage boy's breast reduction surgery on the ground that it was cosmetic must reimburse his father for the operation, an appeals court ruled Tuesday.
The Supreme Court's Appellate Division decision upheld two lower court rulings that directed Group Health Inc. to pay for the surgery because it was "medically necessary" for the boy to lead a normal life.
A GHI spokeswoman said Tuesday she had not seen the decision and could not comment.
In 2004, the then-17-year-old boy's father sued GHI because the insurer refused to pay to reduce the boy's enlarged breasts, a condition known as bilateral gynecomastia. GHI said the surgery was cosmetic and not medically necessary.
Court papers said the teen, of Hempstead, N.Y., was teased by his peers and never engaged in activities that allowed anyone to see his breasts. They said he would not go to the beach and even refused to attend an out-of-state university, fearing dormitory mates would ridicule him.
Manhattan Civil Court Judge Barbara Jaffe found in September 2004 that the boy was unable to function as a normal adolescent because of his condition.
Jaffe said the boy's condition was "an objective, tangible and unusual source of turmoil, more akin to a clubfoot or cleft palate than to a large nose, heavy acne or diminutive breasts on an adolescent female, all of which are relatively common."
Jaffe ordered GHI to pay $5,000 to the plaintiff, the father, who had gone ahead with the breast reduction surgery for his son at a cost of $7,500.
In March 2006, the state Supreme Court's Appellate Term affirmed Jaffe's ruling, and on Tuesday the Appellate Division upheld the Appellate Term.
The Appellate Division judges, ruling 5-0, rejected GHI's argument that the plaintiff's claim of emotional distress was not supported by a mental health professional. The judges wrote:
"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 judges said 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."
A telephone number for the plaintiff, who acted as his own lawyer, could not be found Tuesday.