Class Action Challenges Aetna on Autism

SAN FRANCISCO (CN) - Aetna illegally caps policy benefits for the "only validated treatment" for autism, a mother claims in a federal class action.

Anna M. Sanzone-Ortiz sued Aetna Health of California and its corporate parent on Monday, on her own behalf and for her minor son.

She claims that Applied Behavioral Analysis is "the only validated treatment for people with autism. The treatment approach began in the 1950s. Today, more than 550 peer-reviewed studies have demonstrated the effectiveness of ABA treatment for people with autism. ABA is endorsed by, among others, the U.S. Surgeon General, the National Standards Project, and the National Professional Development Center on Autism."

Aetna capped her policy benefits at 20 hours of treatment per week though her son's treatment provider recommended 26 hours a week, Sanzone says in the complaint.

She calls this limitation without regard for medical necessity illegal under California and federal laws.

After Aetna denied her appeal, Sanzone appealed to the California Department of Managed Health Care in April, which increased her son's weekly coverage to 25 hours, Sanzone says.

She claims that Aetna's cap has no support in literature that validates ABA treatment, which typically finds 30 hours a week the minimum time needed to help patients. It also violates the federal Mental Health Parity and Addiction Equity Act provisions of ERISA by having a separate treatment limitation applicable only in regard to mental health, according to the complaint.

She seeks class certification and an injunction ordering Aetna to cover all "medically necessary" ABA treatment without regard to its arbitrary hour limit.

The 13-page lawsuit does not estimate the size of the prospective class.

ABA is "the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors and to demonstrate that the interventions employed are responsible for the improvement in behavior," the complaint states, quoting the definition without citing a source.

Aetna employs almost 50,000 people and medically insures more than 23 million people, according to the complaint.

Sanzone is represented by Jordan Lewis, with Kelly Uustal, of Fort Lauderdale, and Teresa Renaker, with Renaker Hasselman of San Francisco, who could not reached for comment Tuesday. Aetna did not respond to a request for comment.

Autism, now called autism spectrum disorder, is a developmental disorder that impairs the ability to communicate and interact. It may include repetitive behaviors, though it manifests itself in an extremely wide variety of ways, hence the name spectrum.

Many autistic people are high functioning, such as Temple Grandin, a specialist in animal behavior who designs humane slaughterhouses and has written several best-selling books. A recent development is an autistic rights movement, which prefers the condition not be called a disorder at all, but one of many ways of being human.

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