Group Health Cooperative Sued After Failure to Cover ASD Therapies

On Monday a case was filed in the Western District Court of Wisconsin by an ERISA plan member against Group Health Cooperative of South Central Wisconsin, Inc (GHC). The case regards the improper denial of treatment of the plan member’s child under the Mental Health Parity and Addiction Equity Act (MHPAEA).

The MHPAEA requires that insurance companies provide comparable coverage for mental health or addiction related treatment as are provided for strict medical treatments. This includes not requiring a higher standard of certification for mental health related treatment and not considering treatments to be experimental when they have passed the same standards as medical treatments.

The plaintiff’s child, the complaint said, was diagnosed with Autism Spectrum Disorder (ASD) with developmental issues, including speech delay, inadequate social skills, and poor motor planning and function. Due to these, the child is said to have had difficulties with routine daily activities such as dressing, personal hygiene, and social interactions and had also expressed issues of self harm and depression. The child began receiving treatment to improve these difficulties, including speech therapy and occupational therapy. GHC denied coverage for both therapies, indicating that they were considered experimental for the patient’s age group, despite plan language indicating that ASD was covered and that these treatments could be covered.

The plaintiff is suing for recovery of benefits, breach of fiduciary duty, breach of duty of good faith and fair dealing, and to certify the case as a class action for all other patients subject to this denial. The plaintiffs are represented by Gingras, Cates & Luebke.