Aetna Class Action Lawsuit Filed Over Autism Benefits Cap

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A proposed class action lawsuit has been filed against Aetna Inc. alleging the health insurance company violated mental health laws by placing a benefits cap on the number of hours an autism patient can seek treatment.

Lead plaintiff Anna M. Sanzone-Ortiz of California filed the Aetna class action lawsuit after her autistic son was denied benefit coverage of the physician recommended 36 hours per week Applied Behavior Analysis (ABA) treatment. According to the Aetna benefits cap class action lawsuit, ABA is the only known effective treatment of autism endorsed by the U.S. Surgeon General and the National Professional Development Center on Autism.

Sanzone-Ortiz alleges she is covered under an ERISA-governed health benefit plan sponsored by her employer. According to her Aetna policy, the insurance company will cover services that are deemed medically necessary.

According to the autism coverage class action lawsuit, Aetna defines medically necessary as “health care services and supplies or prescription drugs that a physician or other health care provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating a condition.”

However, the Aetna class action lawsuit claims that when Sanzone-Ortiz sought coverage for the year 2015 for her son’s ABA treatment, she was informed by her insurance provider that they would cap the autism treatment at 20 hours per week. Sanzone-Ortiz appealed their decision to the California Department of Managed Health Care and the department increased her son’s weekly ABA coverage to 25 hours.

Sanzone-Ortiz claims she has exhausted all other courses of action to remedy the situation to get her son the autism treatment he needs. Sanzone-Ortiz claims the Aetna autism benefits cap class action lawsuit would provide an efficient way to settle other similar claims, as potential Class Members have virtually identical questions of the law.

The proposed Aetna lawsuit alleges the insurance company is in violation of the federal Employment Retirement Income Security Act and California’s Mental Health Parity Act.

The California Aetna autism benefits cap lawsuit would be open to all Class Members who are current and former participants and beneficiaries of any ERISA-governed Aetna Health of California health plan who were denied benefits for ABA treatment for autism based on the 20-hour limitation at any time after June 30, 2011.

The Aetna national Class would be open to all Class Members who are current and former participants and beneficiaries of any ERISA-governed health plan that has adopted the Aetna 12-page set of guidelines for determining coverage limits for ABA treatment, who have been denied benefits for ABA treatment for autism based on the 20-hour limit since June 30, 2011.

This proposed Aetna class action lawsuit comes just months after Aetna Life Insurance Co. and Aetna Health Insurance Co. announced a $4.5 million settlement of a Missouri case alleging the company failed to provide autism coverage as required by the state.

Sanzone-Ortiz is represented by Jordan M. Lewis of Kelley Uustal, PLC, and Teresa S. Renaker and Margaret E. Hasselman of Renaker Hasselman LLP.

The Aetna Autism Benefits Cap Class Action Lawsuit is Anna M. Sanzone-Ortiz, et al. v. Aetna Health of California Inc., et al., Case No. 3:15-cv-3334, in the U.S. District Court for the Northern District of California, San Francisco/Oakland Division.