Judge slams Providence Health Plan for wrongfully denying coverage for autistic children

U.S. District Court Judge Michael Simon has ruled Providence Health Plan violated both federal and state mental health parity laws by denying insurance coverage for "applied behavioral analysis" — a form of autism therapy — for children in Portland, Ore., according to a report by The Oregonian.

Parity laws require insurers to provide mental health coverage at least equal to coverage provided for other health conditions. The laws also prohibit health plans from imposing greater financial requirements or treatment limitations on mental health or substance use disorder benefits than on medical or surgical benefits.

The class-action lawsuit was filed against Providence by two families from Portland on behalf of their autistic children. The health insurer denied the children's therapy claims by saying ABA was experimental, according to the report.

However, ABA therapy has become so widely used that legislation was passed in Oregon requiring health plans to cover ABA therapy, with the requirement taking effect in 2016.

The parents appealed Providence's denial to the Oregon Insurance Commission, which ruled ABA therapy is not experimental. Following the commission's finding, Providence denied the children's coverage under a different exclusion for treatment of developmental disabilities. 

The judge ruled Providence was covering mental health conditions at a different level than medical conditions through its broad-based developmental disability exclusion, which is a violation of parity laws, according to the report.

Since 2008, the Oregon Insurance Division has received 34 consumer complaints concerning ABA autism therapy denials, with an external panel of experts overturning the insurance company's denial in more than 85 percent of the cases.

ABA therapy can be life changing for many children with autism. However, the therapy costs $30,000 to $50,000 a year, and without insurance coverage many parents cannot afford the treatment for their children.

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