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Blue Cross Blue Shield of Michigan Forced to Pay for Autism Care In Landmark Case

Posted on: Friday, 19 June 2009, 12:45 CDT

DETROIT, June 19 /PRNewswire/ -- The family of an autistic child filed a motion in federal court today to confirm settlement of a class action against Blue Cross Blue Shield of Michigan. The family alleged in the suit that the insurer wrongfully refused to cover behavioral therapy for children with autism spectrum disorder (ASD), on the baseless ground that the care was "experimental."

Under the terms of the settlement reached at a court-ordered conference on Wednesday, June 17, 2009, Blue Cross has agreed to reimburse all families who paid for behavioral therapy for their children after May 1, 2003, and who were covered under a Blue Cross Blue Shield of Michigan insurance policy. Blue Cross had earlier filed a motion seeking dismissal of virtually the entire case on legal grounds, but the Honorable Stephen J. Murphy III permitted the case to go forward and scheduled the matter for further proceedings, including a settlement conference before Magistrate Michael Hluchaniuk.

The settlement was reached in the case of Christopher Johns v. Blue Cross Blue Shield of Michigan, 08-cv-12272, filed in Detroit. In the suit, the plaintiff alleged that Blue Cross' pattern and practice of characterizing the scientifically established Applied Behavioral Therapy as "experimental," and thus as excluded under its insurance policies, was arbitrary, capricious, illegal and contradicted by many years of scientific validation.

Under the settlement, Blue Cross will pay for behavioral therapy rendered to over 100 children in the last six years. Plaintiff's counsel, Gerard Mantese and John J. Conway, were pleased with the settlement. Mr. Mantese and Mr. Conway issued a joint statement emphasizing: "No insurer should ever take this approach to needed care for children. Applied Behavioral Analysis therapy is supported by science and is not 'experimental.' Delays by insurers in authorizing this treatment, when it is covered by insurance policies, should not be tolerated. Research shows that children with autism spectrum disorder need this therapy early on in life and delaying treatment can irreversibly prevent them from achieving their full potential."

Mr. Mantese emphasized that the settlement includes even families who never submitted a claim to Blue Cross, but who obtained this care for their children and were covered by a Blue Cross policy. Mr. Conway believes that this is the first such settlement addressing Applied Behavioral Analysis (ABA) in the country.

ABA therapy is administered under the supervision of licensed psychologists and other professionals. ABA applies one hundred year old concepts of changing behavior through positive and negative reinforcements. The federal suit in which this settlement was achieved centered upon the ABA treatment provided by prestigious Beaumont Hospital and its HOPE Center, including Dr. Ruth Anan and Dr. Lori Warner.

The case settled shortly after Plaintiff's counsel obtained a court order requiring Blue Cross to produce file documents which validated the effectiveness of ABA therapy for treating children with autism spectrum disorder. Among the documents in the Blue Cross files obtained by Plaintiff's counsel was a draft of a Blue Cross Blue Shield Medical Policy for 2005, which acknowledged the following:

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' own documents further acknowledged that:

The earlier the disorder is diagnosed, the sooner the child can be helped through treatment interventions.

Mr. Mantese stated, "After we compelled Blue Cross through motion practice to produce all materials supporting its position that this care was allegedly experimental, we received numerous file documents which actually established that ABA therapy works and is highly effective in increasing the functioning of these children."

Mr. Conway emphasized, "We are pleased that we were able to obtain a result which will require Blue Cross to pay for this important care and will alleviate some of the financial strain imposed on over a hundred families by having to pay for this care when it was covered under their insurance policies."

Contact information for the families' attorneys follows: Gerard Mantese, Esq. Mantese and Rossman, P.C. 1361 E. Big Beaver Road Troy, Michigan 48083 248-457-9200 Office 248-515-6419 Cell John J. Conway, Esq. John J. Conway, P.C. 645 Griswold St, Ste 3600 Detroit, MI 48226 313-961-6525 Office 313-574-2148 Cell

SOURCE Mantese and Rossman, P.C.

Source: PR Newswire

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