Insurer Must Pay for Boy Breast Surgery

By SAMUEL MAULL

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, a New York appeals court ruled.

The state Supreme Court’s Appellate Division 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 she had not seen the decision released Tuesday 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. Court papers said the teen was teased by his peers 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 the condition. She said it 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 father, who had gone ahead with the surgery at a cost of $7,500.

The Appellate Division judges, ruling 5-0, also rejected GHI’s argument that the plaintiff’s claim of emotional distress was not supported by mental health professionals, noting that "the patient suffers ‘depression’ and ‘emotional distress’ from this condition."

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On the Net:

http://www.nlm.nih.gov/medlineplus/ency/article/003165.htm