Denied Disability Lawsuit Filed

Honolulu, HIThe mother of a young boy with autism has reportedly filed a denied disability lawsuit against Hawaii’s Department of Human Services alleging her son has been denied important treatments that would help him with his autism. The lawsuit is not the first to be filed alleging people with autism are treated improperly when it comes to insurance.

According to Hawaii News Now (9/6/14), Suzanne Egan filed a lawsuit against the Department of Human Services, accusing the department of violating Medicaid rules that require the state to provide treatment for autism.

The treatment, known as applied behavior analysis (sometimes called ABA), reportedly costs around $5,000 a month, a fee too high for the single mother to pay. A spokesperson for the Hawaii Disability Rights Center told Hawaii News Now that 37 states in the US require private insurers to pay for applied behavior analysis, with additional states being ordered by the courts to cover the treatment.

Applied behavior analysis has been the subject of lawsuits before. In 2009, Blue Cross Blue Shield settled lawsuits from 100 families with autistic children, who alleged Blue Cross treated applied behavior analysis as experimental, when in fact years of science confirmed the validity of the treatment.

During that trial, documents from Blue Cross obtained by the plaintiffs spoke of the effectiveness of applied behavior analysis. One medical policy stated that “Applied behavior analysis (ABA) is currently the most thoroughly researched treatment modality for early intervention approaches to autism spectrum disorders and is the standard of care recommended by the American Academy of Pediatrics, National Academy of Sciences Committee and the Association for Science in Autism Treatment, among others.”

Some insurance companies will claim that a treatment is experimental as a way to avoid covering that treatment for a policyholder. Insurance companies will not usually cover experimental treatments because of a lack of evidence of their effectiveness. When that treatment has been proven to be the “standard of care,” however, or has been thoroughly researched and proven effective, insurance companies cannot deny coverage based on the so-called experimental nature of the treatment.

In 2013, regulators in California told insurance companies that they must allow claims for speech and occupational therapy. Three insurers - Health Net, Blue Shield and Anthem Blue Cross - were told that denying access to those treatments was illegal. The companies had allegedly claimed speech and occupational therapy were not medically necessary.

These denials were reportedly given to parents of children with autism and other patients who required such therapies. An independent medical review found that of the speech and occupational therapy denials sent for review, the therapies were medically necessary in 97 percent of the cases.