Anthem’s Autism Coverage Cap OK Under Indiana Law

Employee Benefits News examines legal developments that impact the employee benefits and executive compensation employers provide, including federal and state legislation, rules from federal...

By Jacklyn Wille

Anthem Insurance Cos. didn’t run afoul of an Indiana insurance mandate when it limited coverage for a 13-year-old boy’s autism treatment to 20 hours per week, a federal judge ruled ( W.P. v. Anthem Ins. Cos. , 2017 BL 46549, S.D. Ind., No. 1:15-cv-00562-TWP-TAB, 2/15/17 ).

Anthem satisfied Indiana’s autism mandate, which requires insurers to cover treatment for autism spectrum disorder, by covering 20 weekly hours of treatment instead of the 40 hours requested, the judge ruled on Feb. 15. The judge’s next step will be considering whether this practice violates the federal mental health parity law, a question the judge said will be resolved at trial.

Litigation under the federal mental health parity law—which generally requires insurers to cover mental health services on the same terms that they cover medical and surgical services—has been on the rise since the law’s passage in 2008. T-Mobile USA Inc., Applied Materials Inc. and Regence BlueShield recently settled lawsuits under the parity law by agreeing to lift coverage restrictions for autism treatments. Another Anthem entity, Anthem Health Plans of Kentucky, is facing a certified class action over its autism coverage practices.

In this case, the judge found that the Indiana law didn’t prohibit Anthem from denying or terminating coverage for autism treatment as long as the denial wasn’t solely based on a beneficiary’s autism spectrum disorder and as long as Anthem didn’t impose “less favorable financial limitations” on autism as compared with physical illnesses.

The judge also dismissed the beneficiary’s claim for equitable relief under the Employee Retirement Income Security Act, finding that this claim was duplicative of his claim for wrongly denied ERISA benefits.

Judge Tanya Walton Pratt of the U.S. District Court for the Southern District of Indiana wrote the decision. In a separate order issued the same day, Pratt struck some of the lawsuit’s class action allegations but allowed the plaintiffs to file an amended complaint.

Terrell Marshall and Saeed & Little LLP represent the beneficiary and his family. Katz & Korin P.C. and Reed Smith LLP represent Anthem.

To contact the reporter on this story: Jacklyn Wille in Washington at jwille@bna.com

To contact the editor responsible for this story: Jo-el J. Meyer at jmeyer@bna.com

Copyright © 2017 The Bureau of National Affairs, Inc. All Rights Reserved.

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