1. Case Name: A.G. v. Premera Blue Cross and Lifewise of Washington
2. Type of Treatment Services Denied: Neurodevelopmental therapies for autism
- Plaintiff: Eleanor Hamburger & Richard E Spoonemore, Sirianni Youtz Spoonmore Hamburger
- Defendant: Barbara J. Duffy, Gwendolyn C. Payton & Ryan R. McBride, Lane Powell, PC
4. Format: Order granting Plaintiffs’ Motion for Partial Summary Judgment and Preliminary Injunction and denying Defendants’ Motion to Dismiss
- ERISA Claim? No
- Class Action/or Individual Action: Class Action
- Defendant: Health care service contractors (a/k/a health carriers)
- Type of Insurance Plan: Individual policy issued by Lifewise Health Plan
- Type of Coverage Denial: Medically necessary neurodevelopmental therapy
6. Legal Pointer: The exclusion relied upon by Defendants to deny coverage (the exclusion for “[s]ervices, therapy and supplies related to the treatment of … developmental delay or neurodevelopmental disabilities”) violated Washington public policy and the Parity Act.
7. Legal Issues and Causes of Action: Plaintiff alleged that the exclusion for neurodevelopmental disabilities in the policy violated the Parity Act.
Ruling: Plaintiff’s Motion for Partial Summary Judgment and Preliminary Injunction was granted and Defendant’s Motion to Dismiss was denied.
8. Narrative Case Description: In 2006, Plaintiff was diagnosed with autism. In 2007, Plaintiff’s pediatrician referred him to Valley Medical Center’s Children’s Therapy Program for neurodevelopmental evaluation and therapy. The evaluations by Valley’s therapists recommended that Plaintiff receive weekly occupational therapy and speech therapy.
Plaintiff received neurodevelopmental speech and occupational therapy from Valley Medical Center’s Children’s Therapy Clinic since 2007. Valley submitted the bills for A.G.’s speech and occupational therapy services to Lifewise, which paid for the services for the first twenty visits.
In late July 2011, Plaintiff’s parents received Explanations of Benefits from Lifewise. These documents revealed that Lifewise had conducted a retrospective review of the neurodevelopmental therapy provided to A.G. since January 1, 2010, and determined that all therapy was incorrectly covered. Lifewise determined that nearly $24,000 in neurodevelopmental therapies had been improperly paid, and that A.G.’s parents were financially responsible for all of the treatment. Since Lifewise retroactively denied coverage, Plaintiff lost access to his speech therapy and his occupational therapy was similarly at risk. Without speech therapy, Plaintiff struggled with frequent gagging and choking episodes, as well as visual and auditory comprehension problems, including problems with understanding street signs and written instructions.
A.G.’s father called Lifewise to object to the determination and to request an explanation. On August 12, 2011, Lifewise sent J.G. a letter confirming the decision. Lifewise maintained that there was no coverage for neurodevelopmental therapies because of an explicit exclusion in its policy for neurodevelopmental disabilities.
Plaintiffs’ filed a Motion for Partial Summary Judgment and Preliminary Injunction. The Court concluded that the provision contained in Plaintiff’s health plan that excluded coverage of neurodevelopmental therapies was invalid, void and unenforceable The Court further ordered that Defendants could not apply the neurodevelopmental therapy exclusion in Plaintiff’s contract to his requests for neurodevelopmental therapy services and that Defendants were to review any new claims submitted by Plaintiff and/or his providers for neurodevelopmental therapy as a mental health benefit and consistent with all other provisions in Plaintiff’s contract, including medical necessity.
9. Additional Comments: This matter later settled.
10. Website: None.
11. Practical Implications and Lessons Learned: The Court concluded that money damages were insufficient to compensate A.G. for his resulting developmental loss and enjoined Defendants from enforcing the provision in its contract.
12. All Legal Theories Presented in Case: Violation of Parity Act and Washington public policy
13. Successful Legal Theories in Case: All.