A Dane County couple is suing Group Health Cooperative of South Central Wisconsin, saying the HMO refused to cover treatment as required by state and federal law for their 13-year-old daughter who has autism spectrum disorder.
The suit, by Tony Hensen and Angela Midthun-Hensen of the town of Vienna, near Waunakee, was filed Sept. 27 in U.S. District Court in Madison as a class-action complaint on behalf of children similarly denied coverage of autism treatment at age 10 or older.
“GHC is administering its plans for its own financial benefit rather than the benefit of the plan members, subscribers, and beneficiaries,” the suit says.
Marty Anderson, chief strategy and business development officer at GHC, said the health plan is complying with the state’s mandate for autism coverage. “Determinations are made by physicians and are based upon patient medical history, medical records, insurance plan benefit terms and objective clinical evidence-based research and related criteria,” he said.
The girl, identified only as K.H., started speech therapy in May 2017 and requested coverage of occupational therapy in October 2018, according to the lawsuit. GHC denied coverage of both in January 2019, saying speech therapy was not evidence-based for children with autism 10 and older and occupational therapy is considered experimental for autism, the suit says.
GHC agreed to start covering some speech therapy for K.H. last month, however, the suit says. The HMO has also agreed to cover occupational therapy, for which K.H. is on a waiting list, Paul Kinne, the family’s attorney, told the Wisconsin State Journal.
The lawsuit seeks $18,000 for speech therapy the family paid for and wasn’t covered after K.H. turned 10, Kinne said. She stopped occupational therapy because the family couldn’t afford it, he said.
The lawsuit seeks compensation for other families in similar situations. Kinne said he didn’t have estimates of how many families are involved or what the total amount might be.
Wisconsin requires insurers to cover certain treatments for autism, including intensive-level, evidence-based behavioral therapies for children ages 2 to 9 and nonintensive-level services with no age limit. “This treatment refers to interactive approaches aimed at building skills that help the child reduce problem behaviors. It is also used to improve communication, social, self-care, and learning skills,” according to the Wisconsin Office of the Commissioner of Insurance.
Two federal laws, including a mental health parity act adopted in 2008, also require such coverage, the lawsuit says.
Anderson said he couldn’t confirm that GHC recently decided to cover speech and occupational therapy for K.H.
“Our medical management team maintains policies for various coverages that are based on our internal medical expertise as well as external studies and independent third-party criteria for coverage,” he said. “These medical policies are frequently reviewed and updated based on the best medical evidence available.“
Midthun-Hensen has GHC insurance through her job with the Verona School District. GHC denied an appeal by the family in April 2019, and an independent review organization denied an external review in September 2019, the suit says.