Legal Cases: Autism Spectrum & Learning Disorders

Violation Category: ABA therapy

Short Description: P.S., a six-year-old girl with autism, sought coverage for ABA therapy. Her treatment was denied.

Appeal/Disposition: Defendants’ Motion for Partial Summary Judgment on Plaintiffs’ second claim for relief (disparate treatment), third claim for relief (disparate impact), and forth claim for relief (violation of public policy) based on the one-year statute of limitations was denied. Defendants’ Motion for Partial Summary Judgment on Plaintiffs’ second claim for relief (disparate treatment), third claim for relief (disparate impact), and forth claim for relief (violation of public policy) based on failure to establish the elements of “associational disability discrimination” was denied. Defendants’ Motion for Partial Summary Judgment on Plaintiffs’ claim for injunctive relief based on the claim being “moot” was denied.

Violation Category: Applied Behavior Analysis (ABA) therapy for Autism Spectrum Disorder (ASD)

Short Description: Plaintiffs sought to end Boeing’s allegedly discriminatory practice of excluding all coverage under the Plan for treatment of ABA therapy to treat ASD.

Appeal/Disposition: This case settled. The agreed-upon removal of the exclusion from coverage for the treatment from the terms of the plan, the absence of caps or visit limits, and a $900,000 fund established to pay for retrospective claims, attorney fees, and costs were found to be fair, reasonable, and adequate.

Violation Category: Applied Behavioral Analysis (ABA) therapy for children with autism

Short Description: D.M. alleged that GHC wrongfully denied health insurance coverage to D.M. for ABA therapy. D.M. alleged that the denial of coverage breached the contract for insurance and failed to comply with the Washington MHPA, in violation of the Consumer Protection Act (CPA). The parties stipulated to the filing of early summary judgment motions on the underlying substantive legal issues presented by D.M.’s Complaint. GHC sought the dismissal of all claims and, in turn, D.M. sought partial summary judgment and requested that the Court rule that GHC was in violation of the MHPA.

Appeal/Disposition: The Court found that there were genuine issues of material fact requiring the Court to deny both parties’ motions for summary judgment.

Violation Category: Applied Behavioral Analysis (ABA) therapy for autism

Short Description: Plaintiffs sought partial summary judgment in the form of an injunction requiring Washington Healthcare Authority (HCA) to cover Applied Behavioral Analysis (ABA) for children with autism for whom the service was medically necessary. Plaintiffs aruged that ABA therapy can enable children with autism to attend school, even in mainstream classrooms, or avoid institutionalization.

Appeal/Disposition: The Court concluded that Plaintiffs were entitled to a declaration that specific exclusions contained in health benefit plans administered by the Defendants that excluded coverage of ABA therapy, even when medically necessary and performed by licensed health providers, did not comply with Washington’s Mental Health Parity Act. The Court further declared that under the Mental Health Parity Act Defendants were required to cover medically necessary ABA therapy, as determined on an individualized basis, when provided by licensed providers.

Violation Category: Neurodevelopmental therapies for autism

Short Description: Plaintiff alleged that the exclusion of  “services, therapy and supplies related to the treatment of … developmental delay or neurodevelopmental disabilities” violated Washington public policy and the Parity Act.

Appeal/Disposition: Plaintiff’s Motion for Partial Summary Judgment and Preliminary Injunction was granted and Defendant’s Motion to Dismiss was denied.

Violation Category: Treatment limitations on ABA therapies for ASD and treatment limitations for NDT therapies for pervasive developmental disorder-not otherwise specified and developmental delays

Short Description: Plaintiff alleged that Premera adopted a uniform policy excluding coverage for neurodevelopmental therapy (NDT) to treat DSM conditions for individuals over the age of six and imposed visit limits on such therapies when covered under its “rehabilitation” benefit. Plaintiff further alleged that he was denied coverage for speech and occupational therapy necessary to treat his DSM condition of pervasive developmental disorder-not otherwise specified and developmental delays after reaching visit limits under his rehabilitation benefit. Plaintiff contended that to the extent that Premera provided any coverage of NDT or ABA therapies, it generally imposed treatment limitations that were not at parity with coverage for medical and surgical services.

Appeal/Disposition: The Court granted Plaintiff’s Motion for Preliminary Approval of the class settlement.

Violation Category: Applied Behavior Analysis therapy for Autism Spectrum Disorder

Short Description: Plaintiff argued that T-Mobile adopted a uniform policy excluding any coverage for ABA therapy to treat ASD, including any coverage that may be medically necessary. Plaintiff alleged that he was denied coverage for ABA therapy to treat his ASD, and when Plaintiff appealed, T-Mobile denied his appeals with the justification that ABA therapy was excluded from the Plan.

Appeal/Disposition: Plaintiff’s unopposed Motion to Certify the Class was granted, but the Court denied Plaintiff’s unopposed Motion for Preliminary Approval of the Settlement Agreement.

Violation Category: Plaintiff’s son’s Applied Behavior Analysis (ABA) treatment for his autism spectrum disorder (ASD) was denied.

Short Description: The trial court had stated that the Parity Act only requires coverage for services that are medically necessary, and thus that the question of medical necessity must be asked for each individual in the class. However, the Court states that this is too narrow of a reading, and that the Plaintiff could prove a statutory violation by showing that Defendant categorically denies coverage for coverage that may, in some cases, be medically necessary without considering the question of medical necessity. The Court finds that the Plaintiff’s complaint sufficiently alleges that Defendant has a policy of categorically denying coverage without determining medical necessity.

Appeal/Disposition: Court reversed the order sustaining the demurrer and remanded to the trial court.

Violation Category: Plaintiff was prescribed 40 hours per week of applied behavioral analysis treatment (ABA) for his autism spectrum disorder (ASD). This coverage was reduced to 20 hours.

Short 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.

Appeal/Disposition: 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.

Violation Category: 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 a 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.

Short Description: 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. 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. The Court finds Defendants arguments unpersuasive and that the Exclusion is overtly applicable only to mental health conditions, thus violating MHPAEA.

Appeal/Disposition: The Plaintiff’s motion for summary judgment is granted and the Defendant’s motion for summary judgment is denied.