Dane County family sues health insurer for failing to cover daughter’s treatment for autism
A couple in Dane County are suing to have their health insurer pay for the recommended treatment for their 13-year-old daughter diagnosed with autism spectrum disorder.
Angela Midthun-Hensen and Tony Hensen’s daughter began speech therapy in 2017, but was denied coverage by the couple’s HMO at the age of 10.
Group Health Cooperative of South Central Wisconsin, or GHC, also denied occupational therapy coverage in January 2019, for which parents sought approval. The lawsuit alleges that the denials violate federal and state laws that require insurers to provide coverage for certain conditions and to treat both mental and physical health.
The lawsuit began late last month in Madison U.S. District Court. As a class action suit, it seeks to seek redress on behalf of children in similar situations who have been denied treatment after reaching the age of 10.
The teenager received speech therapy after insurance refused to pay, which cost parents $ 18,000 out of pocket, their lawyer Paul Kinne said.
On September 8, GHC authorized weekly individual speech therapy for the child after initially citing a policy that speech therapy is ineffective for children over 10 years of age.
But the insurer decided that the occupational therapy the parents sought was experimental. The lawsuit says this has left the complainant’s child “unable to get the full treatment she desperately needs.”
GHC denies a claim in the lawsuit that its decision was made to financially benefit the member-owned nonprofit cooperative.
“Our medical management team maintains policies for various coverages based on our internal medical expertise as well as external studies and independent third party coverage criteria. These medical policies are frequently reviewed and updated based on the best medical evidence. available, “said Marty Anderson, director of strategy and business development at GHC.
The lawsuit argues that federal parity law and Wisconsin’s Mandatory Autism Benefits include coverage for the treatment of autism spectrum disorders without limitations or exclusions.
State law currently requires treatment up to the age of 10.
“But there is a federal law that says you must treat mental health as you would any other health care. So, it’s our argument that the science is clear: speech therapy and speech therapy. Occupational therapy continued to be medically beneficial for autistic children even after they turned 10 years old, ”Kinne said.
The lawsuit demands reimbursement from the Hensens and other families who paid out of pocket for autism care. She is also asking for damages for the families who could not receive care.