Via Sacramento Business Journal:
Kaiser Permanente has agreed to pay up to $9 million to settle a class action that alleged the health plan illegally refused to provide behavioral therapy for autistic children before it was mandated by state law.
The lawsuit was filed in Southern California in April 2009 on behalf of Andrew Arce of Los Angeles and others like him. Andrew was 2 years old when Kaiser denied coverage for applied behavioral analysis even though its own doctors said it was medically necessary.
The therapy teaches young children with autism and similar disorders how to eat, communicate, play and learn. It’s expensive; costs go as high as $100,000 a year and the number of children diagnosed with autism continues to climb.
Health plans have balked at paying for the therapy, which they consider educational rather than medical.
Kaiser eventually paid for Andrew’s treatment, but only after the state ordered it to do so. Independent medical reviews of complaints filed with the California Department of Managed Health Care overturned several denials such as this before state law required them to do so, effective July 1, 2012. Kaiser has provided the services since then.
The settlement, announced internally at Kaiser on July 30, requires the health plan to establish a fund of up to $9 million to reimburse any class members who incurred out-of-pocket expenses for applied behavioral analysis or speech therapy before enactment of Senate Bill 946, the law that required them to do so.
If there is any money left over, some of it will go to fund autism research.
Written notification was mailed to class members July 29. All California residents who had health coverage with Kaiser from April 8, 2004 through June 30, 2012 — and dependents diagnosed with autism or related disorders — are covered by the settlement.
“This case involved issues around coverage for services before the law changed, and this settlement does not determine that Kaiser Permanente acted in appropriately,” Kaiser said in a statement. “We believe this settlement is in the best interest for everyone involved.”
Here are links to the settlement notice and to the claim form for reimbursement.