In our special education practice, probably the most common diagnosis our
clients have is autism. Applied Behavior Analysis (ABA) therapy is one
of the few generally accepted and scientifically reviewed interventions
for autism. Under an Indiana law, which is sometimes referred to as the
"autism mandate," health insurance companies are generally prohibited
from excluding (the statute uses the terms "deny, refuse, terminate
or restrict") autism from coverage. Hundreds, if not thousands, of
Indiana children with autism need ABA therapy to gain skills, communication,
and to overcome many of the challenges of Autism. Many families have to
use private providers to get appropriate ABA therapy and services for
their children. This can be expensive, with full-time programs costing
upwards of $30,000 a year. Most families lack the resources to pay for
this out of pocket, so people with health insurance have submitted claims
to receive benefits for ABA.
In response to the large number of claims Anthem, one of the largest health
insurers in the nation, adopted a policy or practice of systematically
reducing benefits for ABA for school age children. According to Anthem,
ABA is available at no cost to families through the public school system
and therefore it was disallowing some of the hours being claimed for private
ABA. Anthem's argument is absurd, akin to denying benefits for a doctor's
office visit and prescription medication for your sick child because he
could have gone to the school nurse.
Anthem policyholders received letters, signed by physicians employed by
Anthem, claiming that ABA (or a certain number of hours of ABA) was not
"medically necessary"-- despite the fact that families had treatment
plans from their own providers recommending ABA. Anthem also reduced benefits
for ABA for school-age children on the basis that ABA is excluded from
coverage as an "educational service" which the public schools
should provide. Some parents challenge the reductions through Anthem's
internal appeals process. Most are probably unsuccessful and give up--which
is exactly what Anthem is counting on.
But one Indiana couple whose son has autism received one of the letters
from Anthem and decided to fight back, filing suit last week in federal
court in Indianapolis and asking to have the case certified as a class
here to see the Complaint.
Generally, the lawsuit alleges that under federal law (ERISA) benefit plans
have to comply with non-preempted state and federal laws. Anthem's
policy or practice of systematically disallowing hours for ABA violates
both the Indiana autism mandate and the federal mental health parity act,
which prohibits "requirements or limitations" on mental health
benefits which are more restrictive than the requirements or limitations
imposed on medical or surgical benefits. It also alleges that Anthem breached
its fiduciary duty to beneficiaries.
The lawsuit represents the best hope for getting insurance coverage for
ABA short of major changes to legislation. Several similar lawsuits have
been filed in other states with favorable results for families.
Our Education Law attorneys help children with autism and other special
needs obtain the services they are entitled to by law from public schools.
Call us today for a free consultation