Providence Health Asks Court to Deny Autism Treatment Class Action

Providence Health Plan has asked District Judge Michael H. Simon of the U.S. District Court for the District of Oregon to deny class action status to plaintiffs suing the company for denial of coverage for autism treatment. If Judge Simon certifies the class action lawsuit, the insurer may be forced to pay for applied behavior analysis treatment for all Oregon children rather than for the original two plaintiffs that were allegedly refused treatment.

Providence is a Catholic health insurance company with a history that dates back to more than 160 years of devoting itself to working with the poor and vulnerable. Plaintiffs in the class action lawsuit, however, allege the insurer has violated federal law by denying coverage for autism treatment.

According to Autism Speaks, “behavior analysis focuses on the principles that explain how learning takes place. Positive reinforcement is one such principle. When a behavior is followed by some sort of reward, the behavior is more likely to be repeated. Through decades of research, the field of behavior analysis has developed many techniques for increasing useful behaviors and reducing those that may cause harm or interfere with learning.”

Applied behavior analysis (ABA) is the use of these techniques and principles to bring about meaningful and positive change in behavior. It’s been employed by behavior analysts with young children with autism and related disorders since 1960s.

Providence  is denying coverage asserting that the behavioral analysis for children is experimental. The company attorney, in his legal brief, explained that the company is pursuing this line of tactic because Providence  has no other legal recourse in case a board physician reviews the case and rules against them on experimental grounds. They argued that not covering this treatment is a legal question and not a medical question.

Brenna Legaard, an attorney herself and one of the mothers spearheading the class action lawsuit, alleges that Provident’s move violated the federal Mental Health Parity Act as well as the federal employer-based insurance law ERISA.

Oregon law allows insurers to refuse coverage for many developmental disabilities, such as tutors and special education. But the law requires coverage for the treatment of autism spectrum disorder. So far, two Oregon insurers are already covering the treatment. A new law is also expected to bring all insurers on board by 2016.

We recently reported here at Top Class Actions about a $2.4 million class action settlement that resolved a dispute between Cigna Corp. and a nationwide class that accused the company of denying benefits for children’s autism treatments that had been deemed by Cigna to be “experimental, investigational or unproven.”

It should be noted that Providence has already lost twice before an independent review board, after the company asserted that the therapy was experimental and ordered it to pay for each child’s treatment.

Providence  may be engaged in a lonely battle here but this will be closely watched when merits of the case are debated next year.