Insurer Must Pay for Boy’s Breast Reduction Surgery, N.Y. Court Rules

April 5, 2007

An insurer that refused to pay for a teenage boy’s breast reduction on the grounds that it was cosmetic surgery must reimburse his father for the operation, an appeals court in New York has ruled.

The Supreme Court’s Appellate Division decision upheld two lower court rulings that directed Group Health Inc. (GHI) to pay for the surgery because it was “medically necessary” for the suburban New York 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, New York, was teased by his peers and never engaged in activities that allowed anyone to see his breasts.

In an earlier ruling, the judge found that the boy was unable to function as a normal adolescent because of his condition.

The judge 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.”

In upholding earlier rulings, the Appellate Division judges called “absurd” GHI’s argument that the plaintiff’s claim of emotional distress was not supported by a mental health professional. GHI must pay $5,000 to the father who paid for the $7,500 surgery out of his own pocket.

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