Benefits Plan Administrator Acted Irrationally in not Covering
the Autism Society of Middle Tennessee and The Bureau of
National Affairs, Inc., Washington D.C.
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A health insurance plan administrator acted arbitrarily and
capriciously in denying coverage of autism- related speech,
integrated sensory, and occupational therapies for a plan
participant's son , the U.S. District Court for the Northern
District of Illinois ruled July 21, 2003 (Wheeler v. Aetna Life
Insurance Co., N.D. Ill., No. 01 C 6064, 7/21/03).
Michael Wheeler participated in a health insurance plan provided
through his employer and administered by Aetna Life Insurance
Co. When Wheeler's son, Bryce, was three years old, he was
diagnosed with autism, speech and language delays, and sensory
Bryce's medical providers submitted bills to Aetna relating to
speech therapy, occupational therapy, physical therapy, applied
behavioral analysis therapy, and sensory integration therapy
Although Aetna initially paid some of these bills, in April 2000
an Aetna representative informed Wheeler that Aetna would not
pay for these therapy treatments because they were not covered
under the plan. Wheeler appealed the denial of benefits and
after a medical review of the records, Aetna again denied
coverage of the various therapy treatments.
Therapies Should Be Covered
Applying the arbitrary and capricious standard of review, Judge
John F. Grady found there was no rational connection between the
evidence submitted to Aetna and Aetna's denial of coverage.
Therefore, summary judgment for the Wheelers was appropriate,
the court said.
The letters justifying the denial of coverage "utterly fail to
consider the actual language of the plan at issue here. The
letters also largely fail to connect Aetna's denial of benefits
to the specific situation and Bryce's diagnosis," the court
Addressing the denial of coverage for speech therapy, the court
said there was support in the medical history from which to
conclude that autism caused Bryce to lose his previously
existing speech skills. Under the plan, speech therapy was
covered if a participant had speech function that was lost as
the result of a disease, which was expected to be restored by
the therapy. The court said Aetna never explained why Bryce did
not meet this test.
Next addressing the denial of coverage for sensory integration
therapy, the court found that Aetna failed to make an
individualized determination of the possible outcome of the
treatment. Instead, Aetna said the effectiveness of the therapy
was unproven and therefore, by implication, unnecessary, the
court said. In doing this, Aetna "failed to consider the express
terms of the plan--the definitions of 'necessary' and
'appropriate,' and it failed to make a rational connection
between the particular medical evidence and its conclusion to
terminate benefits for this therapy," the court said.
Also finding that the denial of coverage for occupational
therapy was arbitrary, the court said Aetna's explanation that
it did not cover long-term occupational therapy for patients
with chronic diseases was not based on any language in the plan.
The court noted the plan was ambiguous regarding the issue of
whether developmental delays were covered if they were caused by
autism. The court found that the developmental delay exclusion
was inapplicable to developmental delays caused by autism,
because otherwise the provision for coverage of autism would be
Leonard D. Saphire Berstein of Law Offices of Leonard Saphire
Berstein, Skokie, Ill., represented Wheeler. Louis Anthony Lehr,
Edward P. Gibbons, and Jennifer Ann Kennedy of Lord, Bissell &
Brook, Chicago, represented Aetna.