Teens With Autism Denied Treatment by Wisconsin Insurance Provider, Class Action Alleges

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Teens with Autism Insurance Coverage Class Action Lawsuit Overview: 

• Who: Group Health Cooperative of South Central Wisconsin (GHC) allegedly violated the Mental Health Parity and Addiction Equity Act and Employee Retirement Income Security Act.
• What: The company allegedly violated the laws by denying speech and occupational therapy to 13-year-old K.H., who is diagnosed with autism.
• Where: The class action is pending in Wisconsin

Group Health Cooperative of South Central Wisconsin (GHC) denies treatment to teens with autism and other mental health conditions in violation of the Mental Health Parity and Addiction Equity Act and Employee Retirement Income Security Act (ERISA), a new class action lawsuit alleges.

The class action lawsuit was filed in Wisconsin on September 27 by lead Plaintiffs Angela Midthun-Hensen and Tony Hensen on behalf of their 13-year-old daughter. Her parents allege that GHC violated the Parity Act and ERISA by denying coverage for recognized therapeutic treatments for their daughter’s autism because she was older than 10 and because the company said the treatments were not evidence-based.

Teen With Autism Denied Treatment Recommended by Doctors 

K.H.’s symptoms include development speech delay, inadequate social skills, and poor motor planning and function, the lawsuit explains, adding that their daughter works hard to gain skills that are easily attainable by her peers.

“Due to her ASD, she struggles with the daily tasks of dressing, personal hygiene, social interaction, and other common every-day activities. As K.H. has gotten older, she has become more aware that she is different from many of her peers and family members, and consequently, has become more prone to outbursts and self-harm.”

The claim outlines how K.H.’s healthcare providers have continuously recommended that she receive treatment called Applied Behavioral Analysis, which is accepted as an effective form of treatment for minors with autism.

She started speech therapy in May 2017 and has made continuous progress and was recommended to have occupational therapy to address delays in developing motor and self-help skills.

However, when her parents contacted GHC to approve occupational therapy (OT) for K.H. in October 2018, the claim was denied, the lawsuit explains. Not only that, but K.H.’s claim for speech therapy was also denied, with the company saying — despite appeals — that speech therapy and OT for K.H. were not covered benefits under the terms of family’s group policy.

GHC further added that the criteria it used for denying speech therapy and OT coverage was its own medical policy, which the family says was used to “justify denial of medically necessary covered benefits” and that “GHC is administering its plans for its own financial benefit rather than the benefit of the plan members, subscribers, and beneficiaries.”

Health insurance plans sold in Wisconsin include mandated benefits. Both the Federal Parity Act and Wisconsin law specifically include autism as a covered benefit, the claim explains.

The family argues that GHC policy’s exclusion is unenforceable as a matter of federal law, and its application to deny coverage to K.H. breached its fiduciary duties as the plan administrator under ERISA.

The family wants to represent anyone who holds GHC Large Group HMO Plans, Large Group POS Plans, and Large Group PPO Plans that contain an exclusion of coverage for applied behavioral analysis, speech therapy for children aged 10 or older. They are suing for violations of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act and Employee Retirement Income Security Act, and seek certification of the Class, declaratory relief, damages, legal costs and fees, and a jury trial.

Aetna faces a similar class action lawsuit filed earlier this month by a consumer who alleges the health care provider discriminates against patients with mental health issues by excluding coverage for them in residential treatment facilities.

Do you think GHC should cover treatments for teens with autism and similar conditions? Let us know your thoughts in the comments section!

The plaintiffs are represented by Paul A. Kinne of Gingras, Thomsen & Wachs, LLP.

The Teens with Autism Insurance Coverage Class Action Lawsuit is Angela Midthun-Hensen, et al., v. Group Health Cooperative of South Central Wisconsin, Inc., Case No.  3:21-cv-00608, in the U.S. District Court Western District of Wisconsin.

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