Michigan Blue Cross faces potential lawsuit over autism care

A lawsuit filed in Wayne County Michigan circuit court may result in Blue Cross Blue Shield of Michigan paying $38,000 in denied claims for autism spectrum disorder treatment plus an additional $87,000, according to lawyers defending the beneficiary.

According to Mantese Honigman Rossman and Williamson, P.C., the law firm handling the case, Judge Prentis Edwards denied the Blue's attempts to dismiss the case, forcing Blue Cross to either settle the claims or go to trial.

In the case of Matthews v. Blue Cross (Case No. 09-018750-CK), Cheryl Matthews alleged that Blue Cross wrongfully refused to pay $38,000 in insurance claims stemming from the known as Applied Behavior Analysis, or "ABA" provided to her autistic son, Matthews' attorneys said. Matthews also happens to be an Oakland County Michigan Circuit Court judge.

Matthews' attorneys claim that earlier this year Blue Cross paid over $1,000,000 to settle a class action lawsuit, Johns v. Blue Cross, No. 08-12272 (E.D. Mich), which also alleged that the insurer had engaged in a pattern and practice of wrongfully denying claims for ABA therapy, according to Matthews' attorneys. Both the Matthews case and the Johns case were handled by attorneys Gerard Mantese and John Conway, who said they devote a large part of their practice to making ABA therapy available to children with autism spectrum disorder.

According to Mantese and Conway, Blue Cross took the position that Matthews' claim should be denied because ABA therapy was not an approved medical treatment under her insurance policy.

The $125,000 amount, which Blue Cross must pay to Matthews, represents three times the cost of therapy and recognized Matthews' argument that her inability to access additional therapy from Blue Cross for her son will result in increased life care costs for her son, Mantese said.

Many other states mandate that insurers pay for ABA therapy for autistic children, but the Michigan legislature has not yet passed a law to this effect, according to Mantese.

"We believe that this is the first settlement in the United States to recognize the link between the inability of children with autism spectrum disorder to access needed ABA therapy and increased life care costs in the future because of the reduced functioning of children with ASD," Mantese said.

John Conway, co-counsel for Matthews, said, "We will continue to bring these suits until all insurers stop making baseless excuses for insuring this needed therapy."

According to Helen Stojic, a spokeswoman for Blue Cross Blue Shield of Michigan (BCBSM), the Blue's attorneys disagree with many of the facts asserted by Mantese Honigman Rossman and Williamson, P.C. about the case. 

The judge did not order BCBSM to pay any amount, Stojic said.

"There was a lawsuit by an individual for past services involving Applied Behavioral Analysis for autism and both parties moved to resolve it," she said. "This was not technically a settlement as there were no settlement negotiations but both parties have agreed to resolve the case for a monetary amount.  This was in lieu of further court proceedings and was accomplished through what is called a case evaluation process."

In addition, Stojic said there was no ruling on the merits of the case and there was not an agreement for BCBSM to pay for past or future treatment nor did the judge make a ruling on "life costs"

According to BCBSM, a lawsuit was concluded in June 2009, after BCBSM and a group of litigants mutually decided to conclude a lawsuit that involved ABA autism coverage, which related primarily to past claims.

As a last procedural step, over past month BCBSM mailed checks to approximately 90 families with BCBSM coverage to pay for ABA services provided through the Gift Program at Royal Oak (MI) Beaumont Hospital. The total amount the families received was $680,000 not $1 million, Stojic said.

According to Stojic, BCBSM is "the most progressive - and is still the only -- Michigan health insurance company to offer the early intervention coverage option for ABA." In May 2009 Blue Cross Blue Shield of Michigan announced it would begin to offer its customer groups (employers) the ability to purchase coverage for autism treatment programs that provide intensive early intervention.  The new benefit option covers children aged two to five years old who use a treatment called Applied Behavorial Analysis (ABA).

"We saw a need in the community and moved to find a way to address it," she said.

 The benefit coverage option, which consists of up to 60 treatment sessions (usually 12 weeks) can be used once per child, will be available for purchase by customer groups that already have outpatient mental health coverage, she said.

"BCBSM still considers ABA experimental and the court proceedings did not change that," Stojic said.


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