1. Case Name: W.P. v. Anthem Ins. Cos., U.S. District Court for the Southern District of Indiana, Indianapolis Division
2. Type of Treatment Services Denied: Plaintiff was prescribed 40 hours per week of applied behavioral analysis treatment (ABA) for his autism spectrum disorder (ASD).
- Plaintiff: Blythe H. Chandler, Toby J. Marshall, Terrell Marshall Law Group, PLLC
- Defendant: Kristopher N. Kazmiercizak, Sally F. Zweig, Kats & Korin, P.C.
4. Format: Entry on Motion for Partial Judgment on the Pleadings
- ERISA Claim? Yes.
- Class Action/or Individual Action: Class action
- Defendant: Defendant is health insurer and claims administrator.
- Type of Insurance Plan: ERISA plan, employer sponsored (unclear whether large or small employer).
- Type of Coverage Denial: Administrative denial
6. Legal Pointer: Plaintiff’s son’s ABA therapy was capped at 20 hours. Plaintiff challenged this cap as improper under Indiana’s Autism Mandate and MHPAEA. The Court did not find these arguments persuasive.
7. Legal Issues and Causes of Action: Violations of Indiana’s Autism Mandate, ERISA, and MHPAEA
- Ruling: Defendant’s motion for partial judgment on Plaintiff’s claim that Defendant violated the Autism Mandate is granted. The Defendant’s motion for partial judgment on Plaintiff’s equitable relief claim for wrongful denial of benefits is granted.
- UPDATE: This case settled. If the proposed Settlement Order is approved by the Court, Anthem will pay nearly $1.63 million for autism coverage claims and will eliminate its guidelines on autism treatment based on an individual’s age. Upon Court approval, Anthem will also issue a statement to its employees regarding the use of age-related considerations and will require employees who review treatment plans to participate in periodic external continuing education related to autism and ABA therapy.
8. Narrative Case Description: Plaintiff’s parents bring the action on behalf of W.P. W.P, is 13 and suffers from severe autism. He has limited verbal skills, is unable to navigate stairs and exhibits repetitive behaviors. W.P.’s provider prescribed 40 hours per week of ABA therapy. Defendant denied this coverage as the plan only covered 20 hours per week for individuals over age 7.
Plaintiffs filed the putative class action asserting the Defendant’s practice of limiting the hours of ABA therapy violates ERISA in that it fails to comply with Indiana’s Autism Mandate and other federal laws. Plaintiffs seek damages, an injunction from the Court and argue that Defendant breached its fiduciary duty to Plaintiffs.
At issue before the court is whether the Autism Mandate permits Defendant to impose a cap on the number of hours of ABA therapy and whether ERISA limits Plaintiff’s ability to seek equitable relief.
The Court sides with Defendant that the limitation on financial requirements is not synonymous with an hour limitation and that the language of the Indiana Autism Mandate does not preclude an insurer from capping the number of hours on ABA therapy.
The Court also sides with Defendant on the ERISA issue. The Court finds that equitable relief is not available under ERISA for denial of benefits claims where the Plaintiff may recover under § 1132(a)(1)(B).
9. Additional Comments: None
11. Practical Implications and Lessons Learned: Use of guidelines on autism treatment based on an individual’s age is not proper.
12. All Legal Theories Presented in Case: Violations of MHPAEA, Indiana Autism Mandate, ERISA
13. Successful Legal Theories in Case: All.