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Article of Interest - Therapy

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Bridges4Kids LogoEmployee Benefits Plan Administrator Acted Irrationally in not Covering Autism-Related Therapies
from 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 integration difficulties.

Bryce's medical providers submitted bills to Aetna relating to speech therapy, occupational therapy, physical therapy, applied behavioral analysis therapy, and sensory integration therapy treatments.

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 added.

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 meaningless.

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.

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