Class Action: Group Health Cooperative of South Central Wisconsin Unlawfully Denied Coverage for Autism Treatment

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Group Health Cooperative of South Central Wisconsin, Inc. (GHC) faces a proposed class action over its allegedly unlawful denial of insurance coverage for certain autism spectrum disorder (ASD) treatments.

According to the case, GHC has used its position as the administrator of group health plans to develop internal policies and practices that “facilitate its coverage denials for autism services.” The lawsuit alleges GHC’s exclusion from coverage of certain treatment and benefits for children with ASD is “baseless, arbitrary, and contrary to law” given the defendant does not apply similar treatment limitations to covered medical and surgical benefits.

Per the suit, GHC has violated both the Employee Retirement Income Security Act (ERISA) and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (Parity Act), a federal law that bars health plans who offer mental health and substance abuse disorder benefits from applying limitations to coverage for mental health and substance abuse disorder treatments that are more restrictive than the standards applied to determine coverage for medical and surgical benefits.

More specifically, the case contends that GHC’s determinations that speech therapy is “ineffective” for children older than nine and that occupational therapy is “experimental” and not medically necessary are “inconsistent with generally accepted medical practices” and limit coverage in a way that is more restrictive than the limitations applied to medical and surgical benefits.

The plaintiffs, beneficiaries of a benefit plan managed by the defendant, claim to have been denied coverage for their 13-year-old daughter’s applied behavioral analysis (ABA) treatment for her ASD. According to the suit, although the daughter’s health care providers have recommended that she undergo speech therapy and occupational therapy, two treatments that have been deemed effective in treating children with ASD up to age 22, the defendant has denied coverage for the treatments.

Per the suit, GHC’s stated reason for denying the plaintiff’s daughter’s speech therapy was that it is not “evidence-based treatment for the core deficits of ASD for children ages 10 and above” and is therefore not a covered benefit under the terms of the policy. GHC allegedly denied the plaintiffs’ request for coverage of their daughter’s occupational therapy because the treatment is, in the defendant’s view, “experimental and investigational,” and not “evidence-based treatment” for ASD.

The lawsuit alleges, however, that Wisconsin law mandates coverage for ASD treatment “without limitations or exclusions.” GHC’s denial of coverage for the plaintiff’s daughter’s speech therapy based solely on her age applies an unlawful limitation to mental health benefits, while applying no similar limitation to medical or surgical benefits, in violation of the Parity Act, the case attests. Moreover, ERISA requires health plans offering dependent coverage to offer such coverage until dependent children turn 26, the suit adds.

The lawsuit further argues that GHC’s “erroneous determination” that occupational therapy is an “experimental” treatment for ASD is not based upon “recognized medical management standards.”

According to the case, both speech therapy and occupational therapy have been proven to be effective treatments for children diagnosed with ASD. By denying coverage for such, the suit contends, GHC has rendered the plan’s coverage for autism treatments “a mere matter of discretion,” and denied children with ASD medically necessary treatment benefits, the case contests.

The plaintiffs allege that without coverage from GHC, they have been forced to pay for their daughter’s treatment out of pocket and forgo “complete treatment, which she desperately needs.”

The case looks to represent all participants, beneficiaries, subscribers and dependents enrolled in the GHC Large Group HMO plans, Large Group POS plans and Large Group PPO plans administered by GHC that exclude coverage for applied behavioral analysis, speech therapy for children older than nine and/or occupational therapy and whose requests for coverage for these services were denied based on GHC’s medical policy (Policy 121).

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