Blue Cross Autism Treatment Class Action Lawsuit

A federal class action lawsuit accuses Empire Blue Cross Blue Shield of refusing to provide benefits for autistic children, “even though it knows that the terms of its plans provide coverage for the treatment.”

The Empire Blue Cross Blue Shield class action lawsuit accuses the insurance company of routinely denying coverage for a condition that is afflicting millions of people in the United States. Autism is growing at a rate of 10 to 16 percent per year, with an estimated 1 in 110 children being born with Autism nationwide. Some estimates, the lawsuit says, predict that the prevalence of Autism could reach 4 million Americans within the next 10 years.

“It is believed that the growing numbers of children diagnosed with autism in America today are driving Blue Cross’ denial of coverage for treatment of this condition,” the class action lawsuit says. “By applying invalid or inoperative policy exclusions to the claims of these parents, Blue Cross is wrongfully denying health care claims totaling tens of millions of dollars in claims as well as dissuading parents from seeking treatment for their children,” the class action says. “Without proper care, treatment, and therapy, Autism can be a debilitating and entirely disabling condition, leading people to grow into adulthood without the ability to perform the most basic of human functions and activities of daily living.”

Applied Behavioral Analysis (ABA) treatment, however, is a scientifically valid, medically accepted and mainstream treatment for Autism that enables Autistic people to learn and perform functions that they would not otherwise be able to accomplish. This is especially true for children who receive early intervention with ABA treatment. Numerous studies show that ABA treatment is the most effective approach for treating children with Autism. Blue Cross, however, refuses to provide coverage for ABA therapy and treatment with “invalid and disproved contract exclusions.” This denial of coverage, the Blue Cross class action says, violates the Employee Retirement Income Security Act (ERISA) and the relevant provisions of class members’ insurance plans.

“Blue Cross’ refusal to provide certain healthcare benefits to a child who suffers form Autism affects the entire family, who must then bear not only the emotional and mental strain of caring for an Autistic child, but also financial devastation…[as] proper medical treatment for an Autistic child can cost tens of thousands of dollars per year,” the class action says.

“Blue Cross has orchestrated a company-wide policy to unduly hamper the processing of claims in violation of its fiduciary obligations, including but not limited to, routinely providing incorrect and invalid reasons for denying coverage. Blue Cross has implemented these polices knowing full well that parents caring for a disabled child often cannot fight the bureaucracy and are likely to simply drop their claims rather than exercise their rights under ERISA.”

The Blue Cross Blue Shield Autism class action lawsuit is brought on behalf of a proposed class of individuals who were or are covered by a health insurance policy from Empire Blue Cross Blue Shield and who made a claim for Applied Behavior Analysis treatment for Autism Spectrum Disorder which was denied on the grounds that such treatment is allegedly not medically necessary and/or that the provider and/or facility is not an approved provider, is not a licensed provider, or is an out-of-network provider when the center had a licensed psychologist and/or a Board Certified Behavior Analyst Supervisor.

The Blue Cross ABA treatment class action lawsuit is seeking an order preventing Blue Cross from denying coverage for ABA treatment on the basis of the approved provider, or investigative or experimental exclusion, in addition to other relief.

A copy of the Empire Blue Cross Blue Shields Autism ABA Treatment Class Action Lawsuit can be read here.