Class Action Claims United Healthcare Wrongfully Denied Coverage for Autism Behavioral Treatment [UPDATE]

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United Behavioral Health and United Healthcare Services face a proposed class action filed by a mother on behalf of her pseudonymous minor over the companies’ alleged denial of coverage for Applied Behavioral Analysis (ABA) treatment for autism.

According to the 18-page complaint, the plaintiff’s son’s autism has led to “increasing aggression, including violent outbursts,” that make it difficult for the 13-year-old to interact with the world around him and for his mother to provide safe and effective care. The lawsuit claims that the plaintiff’s doctors have continuously recommended ABA treatment, which is “generally accepted as an effective form of treatment for minors” with autism spectrum disorder, to focus on improving the boy’s motor skills and adaptive learning techniques. Moreover, the case notes that the American Academy of Child and Adolescent Psychiatry strongly backs ABA treatment, as it’s reportedly been shown to improve the ability of autistic youth to adapt to their environment and engage with others.

Though the plaintiff sought coverage for her son’s ABA treatment under the father’s healthcare plan, the Wipro Limited Plan, United Healthcare and United Behavioral Health denied coverage on the basis that ABA treatment for autism is considered an “intensive behavioral therapy” that’s excluded from the  plan. According to the lawsuit, the exclusion of coverage for intensive behavioral therapies violates the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. 

“As a result, the exclusion is unenforceable as a matter of federal law and Defendants’ application of it to deny coverage to Plaintiff’s son breached their fiduciary duties under the Employee Retirement Income Security Act of 1974 (‘ERISA’),” the case charges. 

As the lawsuit tells it, UnitedHealth Group, the parent corporation of the defendants, announced that it would extend coverage for ABA treatment to all of its fully insured health plans effective January 1, 2017. The announcement, the suit says, came in the wake of 46 states and the U.S. Virgin Islands, as of May 2016, mandating ABA coverage for autism treatment under fully insured healthcare plans. 

Further, the lawsuit states United Behavioral Health’s clinical policy holds that ABA “is proven for the treatment of autism spectrum disorder” when administered by a professional with proper training. Once a patient has been diagnosed with autism spectrum disorder, United Behavioral Health, the case says, will provide ABA treatment coverage for up to eight hours per day or 40 hours per week.

Despite UnitedHealth’s proclamation of ABA treatment coverage for fully insured healthcare plans, the company’s policy and state mandates, the lawsuit claims, do not apply to self-funded­ plans, i.e. plans that pay UnitedHealth an administrative fee to serve as claims administrator and for which benefits are paid from an employer or plan sponsor’s own assets. The plaintiff argues that with regard to self-funded plans, however, state laws are preempted entirely by ERISA regulations.

Summarily, the lawsuit surmises that the defendants’ denial of ABA coverage is almost entirely related to the companies’ bottom lines as they relate to just how much money self-funded healthcare plans bring in.

“Despite recognizing the effectiveness of ABA and the illegality of excluding such treatment from coverage, United continues to enforce ABA exclusions when administering self-funded plans, like the Wipro Plan,” the case says. “It does so because this increases the likelihood that [United Behavioral Health] will be retained by the self-funded plan sponsors to administer their plans. This is highly significant, since approximately 78% of United’s business involves self-funded plans." 

The lawsuit can be read below.