For years, children suffering from severe autism had few therapeutic options for meaningful improvement. Treatment options were limited and largely unproven. Today, however, Applied Behavioral Analysis (ABA) therapy is widely recognized as one of the safest and most effective treatments for autism and 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. For many children with autism, ABA therapy often represents the most effective therapy and the best chance for living a happy and productive life, however, it cannot be a half-measure. Forty years of research and thousands of studies have shown that, for ABA therapy to work, an autistic child must follow a medically-appropriate ABA program—which typically consists of up to 40 hours per week of intensive one-on-one teaching.
This case involves W.P., a 12 year-old child who suffers from severe autism. W.P. has extremely limited verbal skills (his vocabulary consists of 15 words), is able to walk but cannot navigate stairs without assistance and frequently exhibits repetitive, stereotypic behaviors including rocking, flapping his hands, and heavy breathing.
W.P.’s treating physician has prescribed ABA therapy to treat W.P.’s autism. W.P.’s certified ABA therapist designed a treatment plan for W.P. that requires 40 hours of ABA therapy per week. This therapy is medically necessary to treat W.P.’s autism. When W.P. began the ABA treatment plan designed by his therapist, W.P.’s parents observed almost immediate improvements in W.P.’s ability to walk, use words, and respond appropriately to prompts. His stereotypic behaviors also decreased.
Despite this dramatic improvement, in July 2013, Anthem Insurance Company denied W.P.’s therapist’s request for authorization of 40-hours of ABA therapy per week and reduced the number of authorized hours to 25. In July 2014, Anthem further reduced the number of authorized hours to 20. In denying W.P.’s request for benefits, Anthem sent W.P. and his family letters explaining its coverage decisions. Anthem wrote that it would not “approve ABA therapy to take the place of services that can be done through the school.”
As a factual matter, Anthem’s determination that clinical ABA therapy is available through public schools is wrong, but it also reveals a larger, more disconcerting problem: Anthem has adopted an unlawful policy or practice of limiting coverage for ABA therapy to treat autism. As a result, Plaintiff W.P and other Indiana children insured by Anthem have been denied access to medically-necessary ABA therapy to treat their autism.
Anthem’s policy and practice of limiting coverage for ABA therapy for school-aged children with autism violates the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., because it fails to comply with Indiana law and the federal Mental Health Parity Act.
And see a copy of the complaint we filed here: Anthem Complaint Link