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Autism Insurance Dispute Must Be Arbitrated

SAN FRANCISCO (CN) - A federal judge ordered arbitration in a federal class action that claims Aetna illegally caps policy benefits for the "only validated treatment" for autism.

Lead plaintiff Anna Sanzone-Ortiz sued Aetna Health of California and its corporate parent in Federal Court in July, on behalf of herself and of her minor son, who has been diagnosed with autism, under the Employee Retirement Income Security Act.

She claimed that Aetna capped her policy benefits at 20 hours of treatment per week, though her son's treatment provider recommended 26 hours per week. She claims the limitation disregarded medical necessity and is illegal under California and federal laws.

In his Dec. 22 order compelling arbitration, U.S. District Judge William Orrick said that Sanzone-Ortiz "misunderstands precedent on this issue and she is bound by the arbitration agreement she signed."

The arbitration provision in the enrollment request Sanzone-Ortiz completed when enrolling her son in the plan provides in part that "any dispute arising from or related to health plan membership may be determined by submission to binding arbitration, and not by a lawsuit or resort to court process except as California law provides for judicial review," according to the ruling.

Orrick said that Sanzone-Ortiz's complaint "does not directly concern the adverse benefit determination regarding her son's therapy that she has already appealed twice," and the cases on which she relies "do not provide support for her interpretation that the regulations bar arbitration after the claim procedures have been completed."

He found that Sanzone-Ortiz's "mere formulation" of her cause of action "is insufficient to establish 'contrary congressional command' overriding the Federal Arbitration Act."

"Sanzone-Ortiz's argument that she is not bound by the evidence of coverage is unsubstantiated," Orrick wrote.

Sanzone-Ortiz contends she cannot be held to the arbitration agreement because she does not "knowingly exploit the agreement containing the arbitration clause" because her claims are not premised on enforcing the plan. But Orrick said this argument "contradicts allegations present throughout her complaint."

"Here, Sanzone-Ortiz cannot rely on a contract she signed that incorporated the evidence of coverage 'while simultaneously attempting to avoid the burdens that contract imposes,'" the judge wrote.

In addition, Sanzone-Ortiz's "limited reading" of the arbitration agreement overlooks that the arbitration provision applies to HMO affiliates as well as HMOs, and Aetna is therefore an "interested party" and can enforce the agreement.

Neither side's lead counsel responded immediately to emails requesting comment Wednesday afternoon.

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