Mount Sinai Hospital v. Zorek
1966 N.Y. Misc. LEXIS 1741, 271 N.Y.S.2d 1012, 50 Misc. 2d 1037 (1966)
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Rule of Law:
A hospital insurance policy covers a patient's stay if the treating physician determines that hospitalization is medically necessary for a chosen course of treatment, even if alternative, less intensive treatments exist, provided the chosen treatment requires hospital facilities and is not specifically excluded by the contract.
Facts:
- Jane Zorek, who was 5 feet 2 inches tall and weighed over 200 pounds, suffered from obesity and related medical issues like abscesses, cysts, and sebaceous gland problems.
- In 1962, Mrs. Zorek's physician, Dr. John J. Bookman, hospitalized her for sebaceous gland trouble, during which she followed an 800-calorie reducing diet and lost seven and a half pounds.
- Warren Zorek, Mrs. Zorek's husband, had a family Blue Cross contract with Associated Hospital Service of New York (AHS), which paid the expenses for Mrs. Zorek’s 1962 hospital stay.
- After her 1962 hospitalization, Mrs. Zorek was unable to maintain her weight loss and continued to experience recurring boils and cysts.
- In May 1963, Dr. Bookman concluded that Mrs. Zorek required further hospitalization and admitted her to Mount Sinai Hospital for a "Duncan Regime," a rigid starvation diet consisting only of fluids, vitamins, and minerals.
- Mrs. Zorek remained hospitalized for three weeks on the Duncan Regime, losing 17.5 pounds without experiencing adverse effects.
Procedural Posture:
- Mount Sinai Hospital, as plaintiff, sued Warren Zorek, as defendant, in the Supreme Court, Trial Term, New York County, to recover payment for Mrs. Zorek's hospital bill.
- Warren Zorek, as third-party plaintiff, then filed a third-party action against Associated Hospital Service of New York (AHS), as third-party defendant, seeking reimbursement under his family Blue Cross contract.
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Issue:
Does a hospital insurance policy, which covers hospitalization necessary for proper treatment of a condition, obligate the insurer to pay for a patient's stay when the treating physician prescribes a recognized, but dangerous, medical regimen for obesity that requires hospitalization for safe supervision, even if less intensive treatments are available?
Opinions:
Majority - Edward J. Greenfield, J.
Yes, a hospital insurance policy obligates the insurer to pay for a patient's stay when the treating physician prescribes a recognized, but dangerous, medical regimen for obesity that requires hospitalization for safe supervision, even if less intensive treatments are available. Justice Greenfield stated that Blue Cross coverage applies to any "condition" not explicitly excluded, and obesity falls under this. The primary determinant for coverage is whether "hospital confinement is necessary for his proper treatment." The court held that the "applicable standards of judgment as to the treatment prescribed must be those of the treating physician." It emphasized that once a treating doctor decides on a treatment for which hospitalization is necessary, their judgment cannot be retrospectively challenged by the insurer. The court recognized the "Duncan Regime" as a legitimate, though controversial, medical treatment for obesity, which Dr. Bookman, within his medical competence, deemed necessary for Mrs. Zorek. Furthermore, given the inherent dangers and potential for sudden, drastic changes associated with the Duncan Regime, the court found that constant, 24-hour medical supervision in a hospital setting was medically necessary, making it irresponsible to administer such a diet outside a hospital. Thus, Mrs. Zorek's stay was for medical necessity, not merely custodial care or a "rest cure" as argued by AHS.
Analysis:
This case establishes an important principle regarding deference to a treating physician's judgment in determining medical necessity for insurance coverage. It clarifies that if a physician chooses a medically recognized, albeit potentially dangerous, treatment that requires hospitalization, an insurer cannot deny coverage simply because alternative, less intensive treatments exist or because the patient's condition (e.g., obesity) might be manageable outside a hospital in other circumstances. The ruling shifts the focus from the nature of the condition itself to the medical necessity of the chosen treatment and its required setting. This could protect patients and physicians from retrospective second-guessing by insurers, particularly for complex or controversial medical conditions.
