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Oregon Suit Against Providence for ABA Denials Gets Boost

January 03, 2014

PORTLAND (January 3, 2014) -- A complaint filed in federal court here against Providence Health Plan for  denying claims for Applied Behavior Analysis (ABA) therapy for autism will move forward as a class action affecting all Providence policyholders in Oregon.

U.S. District Court Judge Michael Simon granted the motion of two families who filed the complaint last May to certify the suit (A.F. and A.P. v Providence Health Plan) as a class action. The complaint challenges Providence's denial of claims for ABA coverage based on its policy of excluding any benefits "related to developmental disabilities, developmental delays or learning disabilities.”

Providence included the blanket exclusion in all of its group plan insurance contracts issued after 2007. Insurers have typically denied ABA claims based either on the blanket exclusion or by contending the therapy is "educational" or "experimental." The complaint is directly solely at the blanket exclusion policy. 

Brought by the parents of two children, "A.F." and "A.P.," the complaint alleges the denials violate the federal 2008 Wellstone Domenici Mental Health Parity and Addiction Equity Act, Oregon's Mental Health Parity Act, and a state statute requiring that children with pervasive developmental disorders, such as autism, receive “all medical services, including rehabilitation services, that are medically necessary and are otherwise covered under the plan.”

The mother of A.P., Lucia Alonso, lost her home to foreclsoure when she could no longer afford both her mortgage and paying her child's ABA bills out-of-pocket due to the lack of insurance coverage.

After the complaint was filed last year, the Legislature passed and Gov. John Kitzhaber signed a bill requiring all state-regulated health insurers to cover the diagnosis and treatment of autism. The provisions will start to apply in 2015 for state employees and in 2016 for families holding individual, small group or large group health plans regulated by the state. Self-insured "ERISA" plans are exempt because they are regulated under federal law which does not require autism benefits.