Insurance Companies Forcing Policyholders to File Lawsuits to Obtain Benefits

Dallas, TXWhen you're dealing with a disability or serious illness and are unable to work, the last thing you want to do is fight with your insurance company over denied disability benefits. But that's exactly what denied disability lawsuits allege has happened, over and over again. Policyholders say their insurance claims are improperly denied or delayed so companies can protect their profits. And according to a PBS report, children are also suffering because of insurance decisions.

On July 7, 2016, PBS NewsHour ran an article about Texas denying Medicaid coverage for certain autism therapy. The story focuses on Braulio De La Cruz, whose son Noah was diagnosed with autism in 2015. Braulio attempted to get coverage for Applied Behavioral Analysis (ABA), but the Texas Medicaid program refused to cover behavioral therapy. Not only has it denied future treatments to children with autism, it also refused to reimburse for therapy already obtained when Texas reversed a decision on already approved ABA.

Braulio has had to obtain his own individual insurance plan, but he pays $198 a month and has premiums of $6,500.

The Centers for Medicare & Medicaid Services (CMS) issued a directive that the states must provide funding for all medically necessary care required for children up to age 21 who are eligible for Medicaid. Although the CMS did not explicitly state ABA in that directive, those in favor of ABA say if a doctor deems the therapy medically necessary, it should be included in funding. California and other states have already put in policies covering ABA, but Texas has not.

In some cases, where insurance companies have refused to cover specific treatments on the grounds they are experimental or not medically necessary, policyholders have filed lawsuits against their insurance companies. In 2015, the parents of a boy (referred to as W.P.) with severe autism filed a lawsuit against Anthem for restricting his benefits. Although W.P. was prescribed 40 hours of ABA therapy, Anthem told the family he could either get 20 hours or find a new insurance company.

Anthem reportedly told the family the ABA treatment was not medically necessary. According to WTHR, the family filed a class action lawsuit against Anthem.

"Applied Behavioral Analysis (ABA therapy is widely recognized as one of the safest and most effective treatments for autism," the lawsuit states. "It has been endorsed by numerous state and federal agencies, including the U.S. Surgeon General, the National Institute of Mental Health, the American Psychological Association, and many state Departments of Health."

Despite this, some insurance companies and agencies are still reportedly taking their time covering the therapy, forcing policyholders to either pay for the therapy themselves, forgo it, or file a lawsuit to have ABA covered. In the case of W.P., Anthem reportedly told the family that he could obtain similar services through the school.

The lawsuit is case number 1:15-cv-00562, in the US District Court for the Southern District of Indiana.