In what plaintiffs lawyers are calling a landmark autism case, a Michigan insurance company has agreed to reimburse at least 100 families for costs involving treatments for their autistic children.
The $1 million class action settlement from Blue Cross Blue Shield of Michigan comes amid a legislative wave in which a growing number of a states are passing laws that require insurance companies to pay for autism treatments and screenings. To date, 13 states have such laws, the most recent being Connecticut, Colorado and Nevada. New Jersey is currently considering an autism bill, and Pennsylvania's law goes into effect July 1.
The June 17 Michigan settlement, meanwhile, has autism advocates hopeful that insurance companies will stop claiming that behavioral therapy for autistic children is experimental, and start paying for it.
"It is a significant victory for the families, obviously, and it marks a trend, hopefully, that insurance companies will start to look at autism treatment differently," said Areva Martin, an attorney at Los Angeles-based Martin & Martin who is currently handling about 30 autism cases. She believes the labeling of autism treatments as experimental is "absurd."
"It's a neurological condition similar to a patient that has a stroke," Martin said.
In the case, Johns v. Blue Cross Blue Shield of Michigan, filed in the Eastern District of Michigan, the family of an autistic child sued Blue Cross for allegedly failing to acknowledge that a treatment known as applied behavioral analysis is scientifically valid. ABA therapy attempts to change behavior through positive and negative reinforcements.
In the suit, the plaintiffs alleged that Blue Cross' pattern and practice of characterizing ABA as "experimental" was arbitrary, capricious, illegal and contradicted by many years of scientific validation.
Blue Cross sought dismissal of the case, but a judge permitted it to go forward.
The case settled shortly after plaintiffs counsel obtained a court order requiring Blue Cross to produce documents that validated the effectiveness of ABA. Among the documents obtained was a draft of a 2005 Blue Cross Blue Shield medical policy, which stated: "Applied behavioral analysis (ABA) is currently the most thoroughly researched treatment modality for early intervention approaches to autism spectrum disorders and is the standard of care recommended by the American Academy of Pediatrics, National Academy of Sciences Committee and the Association for Science in Autism Treatment, among others."
Blue Cross' documents also stated: "The earlier the disorder is diagnosed, the sooner the child can be helped through treatment interventions."
"I think we had 'em. Their files were so damming," said Gerard V. Mantese, of Troy, Mich.'s Mantese & Rossman, one of two lawyers who represented the plaintiffs. "We kept hearing from Blue Cross that this is experimental, we've researched it. So when we sent our discovery requests saying, 'Show us what you have,' their file looked almost like my file. It had paper after paper supporting ABA therapy."
Under the settlement, Blue Cross will pay for behavioral therapy rendered to more than 100 children in the past six years. Mantese believes this is the first such lawsuit settlement where an insurance company has agreed to pay for autism treatment.
"We've searched across the country for similar cases. This is the first one that we're aware of," said Mantese, who is getting calls from numerous attorneys handling similar cases. "I'm getting calls from all across the country. They're encouraged. They're pleased with the settlement, and they're motivated to fight for these families and these children."
Jeffrey Rumley, vice president and general counsel for Blue Cross Blue Shield of Michigan, issued this statement: "We knew we could resolve this matter to the benefit of the families involved, and are pleased to be able to conclude this matter in a manner that puts the families first who received services from the early intervention program," Rumley stated.
Separate from the lawsuit, Blue Cross Blue Shield of Michigan announced on May 11 that it will offer its customer groups the ability to purchase coverage for autism treatment programs that provide intensive early intervention. The new benefit option involves coverage for children aged two to five years old who use ABA, although the insurance carrier said that it still considers ABA an investigational and experimental treatment.
The coverage will begin on July 1.
"We saw a need in the community and moved to find a way to address it," said Thomas Simmer, M.D., Blues Cross Blue Shield of Michigan senior vice president and chief medical officer, when announcing the new coverage last month. "We developed this coverage option as part of our commitment to improving the health and wellness of all Michigan children and families."
