On May 19, 2015, Governor Jay Nixon announced that Missouri had reached a $4.5 million settlement agreement with Aetna. The insurance company had failed to provide coverage for the diagnosis and treatment of autism in violation of a 2010 law mandating that insurance companies operating in Missouri provide such coverage.
In particular, the 2010 law requires insurance companies to cover one of the most highly effective types of autism therapy, Applied Behavioral Analysis, or ABA. While effective at treating autism, ABA can cost tens of thousands of dollars each year, meaning that most families depend on insurance coverage to pay for the treatment.
The settlement includes the largest fine in Missouri history for insurance law violations. It also allows the Missouri Department of Insurance to suspend Aetna from doing business in the state for up to one year if it violates the agreement during a three-year monitoring period.
This action sends a powerful message to other insurance companies in Missouri, such as United Healthcare, Cigna, Anthem and Blue Cross Blue Shield, that they must cover ABA therapy for autistic children. However, it is often up to individuals to hire a lawyer to enforce the provisions of their Health Plan and force insurance companies to pay for ABA therapy. The lawyers at Gallagher Davis are experienced in helping families and therapy providers fight denials for ABA therapy. Health insurers work hard to find ways around state laws like Missouri’s ABA therapy coverage requirement in order to save money and deny claims. Health Plans that are exempt from state law, such as self-funded ERISA plans, often try to argue that ABA therapy is experimental, that therapy providers are not qualified, or that only a very limited amount of therapy sessions are authorized. In these situations the Missouri Department of Insurance offers little help and the only way to force an insurance company to pay for therapy may be to hire a lawyer experienced in fighting ABA therapy coverage denials.