PARITY LITIGATION ANALYSIS
1. Case Name: A.F. v. Providence Health Plan, United States District Court for the District of Oregon, August 8, 2014
- Keith S. Dubanevich, Joshua L. Ross, Nadine A. Gartner; Stoll Stoll Berne Lokting & Schlachter, P.C.
- Megan E. Glor; Attorneys at Law, P.C.
- William F. Gary, Arden J. Olson, Aaron Landau; Harrang Long Gary Rudnick, P.C.
- Aaron T. Bals, Harrang Long Gary Rudnick, P.C.
3. Format: Published opinion and order on Plaintiff’s motion for summary judgment and insurer’s motion for summary judgment.
4. Outline: Plaintiffs A.F. and A.P. are dependent beneficiaries diagnosed with Autism Spectrum Disorder and prescribed ABA therapy. Defendant denied coverage of the therapy because it is a “service related to developmental disabilities, developmental delays or learning disabilities” (the Developmental Disability Exclusion). Defendant otherwise covers services related to Autism. Plaintiffs bring this motion for summary judgment based on Defendant’s violation of the Oregon Mental Health Parity Act, the Oregon Mandatory Coverage for Minors with Pervasive Developmental Disorders Act and the Federal Parity law.
- Medical Necessity/Administrative: Administrative
- Class Action/Individual: Class Action
5. Relation to Parity Implementation: This case questions whether the Developmental Disability Exclusion violates MHPAEA in that it is a treatment limitation applicable only to MH/SU claims. The Court also examines whether a treatment limitation is subject to only quantitative limitations, as argued by the Defendants.
6. Legal Issue: The question is whether the insurer violated MHPAEA and other state law when it purported to cover autism but denied coverage for medically necessary ABA treatment through its developmental disability exclusion.
7. Ruling: The Plaintiff’s motion for summary judgment is granted and the Defendant’s motion for summary judgment is denied.
8. Causes of Action: Violations of the Oregon Mental Health Parity Act, the Oregon Mandatory Coverage for Minors with Pervasive Developmental Disorders Act and the Federal Parity law
9. Court and Jurisdiction: Federal; U.S. District Court for the District of Oregon
10. Treatment at Issue: Applied behavioral analysis
- Service: applied behavioral analysis (ABA) – an early intensive behavioral interaction health service that helps people with autism to perform social, motor, verbal, behavior, and reasoning functions
- Diagnosis: Autism
- Mental Health/Substance Use/Eating Disorder/Other: Mental Health
- Level of Care: Outpatient
11. Type of Insurance Involved: Group health insurance, not self-insured
12. Case Description: Plaintiffs claims for ABA therapy were denied because it is a service subject to the Developmental Disability Exclusion. Plaintiffs argue the Exclusion violates both Oregon law and MHPAEA.
In examining Oregon state law, the Court looks at the text and context of the statute, then the legislative history, and finally the court may look at general maxims of statutory construction. In looking at the Oregon Mental Health Parity Act, the Court found that the text and the legislative intent both support the Plaintiff’s argument that the Exclusion is unlawful. The Exclusion does not provide equal coverage to medical/surgical benefits and is inconsistent with the spirit of the statute.
Similarly, in its examination of the Oregon Mandatory Coverage for Minors with Pervasive Developmental Disorders Act, the Court found that the Exclusion is unlawful. The Act requires health benefit plans to cover treatment of pervasive developmental disorders for children. Autism is included in the definition of a pervasive developmental disorder. The Court ultimately found that the Exclusion, on its face, violates the Act, holding “(t)he text, context, and legislative history thus make it clear that an insurer cannot provide coverage for a service for one child and deny coverage for the same service for another child solely because the second child suffers from a developmental disability.”
Finally, the Court examined whether the Exclusion is unlawful under MHPAEA. The Defendant argues that MHPAEA does not require coverage of any specific treatment but only requires that if a certain treatment or service is covered that it must be covered equally for MH/SU and medical/surgical claims. Plaintiffs argue that the Exclusion violates MHPAEA in that it is a treatment limitation applicable only to mental health disorders. Defendants counter this argument by saying that under ejusdem generis (general words should be interpreted consistently with the specific words they follow) the term ‘treatment limitations’ refers to quantitative limits only. The Court finds Defendants arguments unpersuasive and that the Exclusion is overtly applicable only to mental health conditions, thus violating MHPAEA.
13. Additional Comments: None
15. Analysis and Lessons Learned: A blanket exclusion may raise questions as to whether it is lawful under both state and federal Parity laws. Oregon’s parity law seems to be well developed and contains many protections – this will not be the case in every state.
16. All Legal Theories Presented in Case: Violations of Oregon Parity Act, Oregon Mandatory Coverage for Minors with Pervasive Developmental Disorders Act, and MHPAEA
17. Successful Legal Theories in Case: Violations of Oregon Parity Act, Oregon Mandatory Coverage for Minors with Pervasive Developmental Disorders Act, and MHPAEA (all three claims were successful)
18. Relevant State Laws: Oregon Mental Health Parity Act, Or. Rev. Stat. § 743A.168; Oregon Mandatory Coverage for Minors with Pervasive Developmental Disorders Act, Or. Rev. Stat. § 743A.190