Aetna Hit With Class Action in California for Capping Autism Treatment

A mother from California has filed a class action lawsuit against Aetna, for allegedly unjustly cutting off autism benefits for her son in violation of California law.

Plaintiff Anna M. Sanzone-Ortiz, who has employer-sponsored health insurance for herself and her family through Aetna Health of California Inc., says that her son’s health provider recommended 36-hours per week of Applied Behavioral Analysis to treat his autism, but Aetna’s policies limit the benefit to 20-hours per week.

Also called ABA, this form of behavioral health therapy is a strategic form of autism treatment geared toward reading, living skills, social skills, academics, and other important social capabilities.

When Sanzone-Ortiz told Aetna her son needed ABA treatment, Aetna capped the weekly hours at 20. She calls this limitation without regard for medical necessity, which is illegal under California and federal bad faith insurance laws.

After appealing the Aetna’s decision, Sanzone-Ortiz received written notice that Aetna found “insufficient scientific support to determine in advance the optimal frequency, duration or intensity of ABA needed for a particular individual.”

Sanzone-Ortiz then sought help from the California Department of Managed Mental Health Care, which increased her son’s treatment to 25-hours per week.

Now, Sanzone-Ortiz hopes to join forces with others who suffered the same bad faith insurance practices from Aetna. She seeks class certification and an injunction requiring Aetna to cover medically necessary ABA autism treatment regardless of the 20-hour cap and compensation for out-of-pocket expenses incurred due to the cap.

About ABA Therapy

Autism Spectrum Disorder or autism is a group of complex disorders of brain development. The Centers for Disease Control and Prevention (CDC) identifies around 1-in-88 American children as on the autism spectrum.

Without proper treatment, autism is a debilitating condition, leading people to grow into adulthood without the ability to perform even basic functions and activities of daily living.

The most common and recognized method of treating autism is Applied Behavior Analysis, or ABA. ABA is a science that uses behavioral techniques to teach children basic and complex skills.

Changes do not typically occur quickly and most children require intensive and ongoing instruction that builds on their step-by-step progress. Without these skills, many diagnosed with autism will experience the debilitating and disabling effects of the disorder.

Bad Faith Insurance: ABA Therapy Litigation

In May 2015, Aetna Life Insurance Co. and Aetna Health Insurance Co. reached a $4.5 million settlement in Missouri over state required autism therapy coverage.

Additionally, a putative class action lawsuit against ConAgra Foods Inc. and Blue Cross Blue Shield was filed in a California federal court over bad faith insurance allegations, alleging the companies improperly denied ABA therapy to a ConAgra employee’s child.

In 2014, Cigna Corp. was also accused of bad faith insurance practices for allegedly denying coverage for ABA autism Therapy and settled the nationwide class action lawsuit for $2.4 million.

California law now requires health insurance companies, like Aetna, to fund your child’s therapy such as Applied Behavior Analysis (ABA) and others.

If you have a valid insurance claim that you feel has been wrongfully denied, an attorney experienced in bad faith insurance can be help you to recover the autism therapy benefits you deserve.

The Aetna Bad Faith Insurance 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.

Join a Free California Bad Faith Insurance Lawsuit Investigation

A bad faith lawsuit investigation has been launched into allegations that some California insurance companies are refusing to pay valid medical claims or offering to pay far less than the claim is worth. Some of the companies being investigated for potential violations include:

• Aetna
• Anthem Blue Cross
• Blue Cross of California
• Blue Shield of California
• Cigna
• Health Net
• Kaiser
• Secured Horizons
• United Healthcare
• WellPoint
• Others

If you or a loved one were denied coverage for autism treatment, mental health treatment, plastic surgery skin removal after weight loss, proton therapy for cancer, or some other medically necessary treatment, you may have a legal claim.

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