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Providence's Autism-Related Coverage Denials Violated Mental Health Parity, Court Finds

Tuesday, August 12, 2014

Aug. 11 — Providence Health Plan violated state and federal mental health parity laws by denying coverage for certain autism-related behavioral treatments, the U.S. District Court for the District of Oregon concluded.  

Judge Michael H. Simon ruled Aug. 8 that the insurer's failure to cover applied behavior analysis (ABA) therapy violated the federal mental health parity act, because it imposed a treatment limitation on mental health benefits that didn't apply to other types of benefits.

The coverage denials also violated Oregon law mandating mental health parity and coverage for minors with developmental disorders, the court determined.

Class Action

The participants filed a class action challenging Providence's use of its developmental disability exclusion to exclude ABA therapy from coverage. According to the court, ABA therapy is an intensive behavior therapy that measures and evaluates observable behaviors and may provide significant benefits to children with autism.

The court certified the suit as a class action in December 2013.

In January, an Oregon-based nonprofit group that supports individuals with disabilities filed an amicus brief on behalf of the participants.

Oregon Law Violated

In the instant ruling, the court agreed with the participants that Providence's coverage denials violated the Oregon Mental Health Parity Act.

The court said that, while Providence could decline to cover autism altogether, it couldn't “simultaneously purport to cover autism and yet deny coverage for medically necessary ABA therapy through its Developmental Disability Exclusion.”

Further, the court said that the exclusion on its face violated the Oregon Mandatory Coverage for Minors with Pervasive Developmental Disorders Act, which requires health plans to cover treatment for children with pervasive developmental disorders.

Federal Parity Law

Finally, the court determined that the exclusion violated the federal mental health parity act.

The court explained that the exclusion constituted an impermissible treatment limitation on mental health benefits, because it limited the treatment of plan members with developmental disabilities.

Given this, the court granted the participants' motion for partial summary judgment.

The participants were represented by Stoll Stoll Berne Lokting & Shlachter PC. and Megan E. Glor, Attorneys at Law PC. Providence was represented by Harrang Long Gary Rudnick PC.

Text of the opinion is at http://www.bloomberglaw.com/public/document/AF_by_and_through_his_parents_and_guardians_Brenna_Legaard_and_Sc.

  

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