LANSING, MI Blue Cross Blue Shield of Michigan was wrong to deny coverage for a certain autism treatment, a U.S. district court judgeruled.
The Detroit-based insurer rejected claims for applied behavior analysis, contending the autism treatment was investigative or experimental. Judge Stephen J. Murphy III ruled last week that the basis for denial was arbitrary and capricious and sent the claims back for reconsideration.
The ruling could impact about 500 families who had to pay for coverage out of pocket since 2010, said Troy attorney Gerard Mantese, who represented parents of autistic children in the class-action suit. He estimated it could amount to some $5 million in payments from Blue Cross.
This ruling is great news for hundreds of families who are working hard to provide a great life for their children who have autism, he said.
Blue Cross has not decided whether it will appeal.
We understand the concern and are very sympathetic to the challenges of families dealing with autism, Blue Cross spokeswoman Helen Stojic said in a statement.
She said it was the first Michigan health plan to offer a rider for ABA starting in May 2009. Mantese argued that families shouldnt have had to get a rider and that the treatment should have been covered under regular mental health coverage.
Applied behavior analysis has been recognized as effective by many health organizations and is now part of mandated coverage under a state law that passed last year.
The law doesnt apply to self-funded plans, but the recent court ruling applies to employers self-funded plans administered by Blue Cross. The court order is limited to past claims.
On Monday, Michigan also began providing coverage for applied behavior analysis treatment for young children with autism through Medicaid and MIChild programs. Mantese said that coverage is the result of another lawsuit brought by his law firm, Mantese Honigman Rossman and Williamson in Troy.
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US judge: Blue Cross Blue Shield of Michigan wrong to deny autism treatment coverage