Oregon Court Rules Autism Coverage Wrongfully DeniedImage Banner

Oregon Court Rules Autism Coverage Wrongfully Denied

You are here

Oregon Court Rules Autism Coverage Wrongfully Denied

August 14, 2014
A U.S. District Court in Portland, Oregon has ruled that Providence Health Plan erred when it denied insurance coverage for autism therapy for two minors. The judge in the case ruled that the insurance company's denial of coverage violated federal and state mental health parity laws. The parity laws require that annual or lifetime caps on mental health benefits be at least as much as those for medical or surgical benefits. The service at issue in the case was Applied Behavioral Analysis (ABA), a type of autism therapy which continues to gain popularity among family members of and service providers for people with autism. With an annual cost ranging, on average, from $30,000 to $50,000, paying for ABA is a challenge for many people affected by autism.
 
Last year, the Oregon Legislature passed a bill that will require health insurance companies to pay for ABA starting in 2016. Insurers in the state considered that bill to represent a new mandate, which, under the Affordable Care Act (ACA), they would be able to recoup the additional cost of compliance from the state.  
 
The case was brought by the parents of two boys who were denied claims for ABA by their insurer. The insurer denied the claims on the grounds that the therapy was "experimental." Prior to filing the case, the parents appealed the denial to the state insurance division, which determined, after hearing testimony from the parents and a panel of doctors, that the ABA was appropriate treatment, and the claims should have been paid. The insurer then denied the claims citing a different policy exclusion for treatment of developmental disabilities. 
 
The most recent ruling in the case partially granted the parents' motion for summary judgement, which puts it in the stage where remedial damages will be determined. This case is being watched closely by people involved in supporting individuals with autism, as it tends to further bring ABA therapy into the mainstream. 
 
Source: The Oregonaian