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UnitedHealth must cover 'core' autism treatment, court rules

A UnitedHealth Group Inc unit ran afoul of a federal mental healthcare law by refusing to cover a “core” treatment for autism through an employee health plan it administered, a federal judge has ruled.

U.S. District Judge Yvonne Gonzalez Rogers in Oakland, California ruled Friday that the plan’s exclusion of a form of therapy called applied behavior analysis (ABA) violated the Mental Health Parity and Addiction Equity Act, ruling in favor of an anonymous plaintiff who sued United Behavioral Health on behalf of her son.

“It is tremendously significant that the court found this exclusion of coverage for the most widely used autism treatment to be illegal, and that the nation’s largest health insurer can be liable under federal law for enforcing it,” Caroline Reynolds of Zuckerman Spaeder, a lawyer for the plaintiff, said in a statement. “Because this exclusion has been in many United-administered plans for years, there are likely to be thousands of other children and families who have been similarly affected.”

“UnitedHealthcare covers ABA therapy based on individuals’ benefit plans and will continue to defend itself in this matter,” the insurer, which is represented by Jennifer Romano of Crowell & Moring, said in a statement.

Plaintiff “Jane Doe” filed the 2019 lawsuit on behalf of her son, “John Doe,” against UnitedHealth in its capacity as administrator of a health plan covering employees of information technology company Wipro Ltd, where John Doe’s father worked until February 2020.

She alleged that the insurer breached its fiduciary duty under the Employee Retirement Income Security Act when it refused to cover ABA for John Doe between 2017 and 2019, under a plan provision that specifically excluded ABA coverage for autism.

Jane Doe said the exclusion violated the Parity Act, which requires that large group health plans’ coverage of mental health treatment be no more restrictive than non-mental health treatments, and that plans include no exclusions that apply only to mental health plans.

UnitedHealth moved for summary judgment on the grounds that, as a third-party administrator, it was not a fiduciary and could not override the terms of the plan. It also sought summary judgment that the ABA exclusion did not violate the Parity Act, arguing that the law targeted financial or quantitative limits, such as caps on number of visits, for mental health treatment.

Doe also cross-moved for summary judgment.

Rogers, siding with the plaintiffs, rejected both of UnitedHealth’s arguments. She said that the insurer’s power to make claims determinations made it a fiduciary, and that its fiduciary duties overrode plan terms.

“Here, United Health cannot hide behind the plan terms, especially where ERISA imposes specific and independent duties on its fiduciaries to otherwise comply with the provisions of ERISA,” she wrote.

She also found that the language of the Parity Act clearly forbids the plan’s exclusion of ABA for a mental health condition.

“The exclusion carves out and rejects from coverage a core treatment for Autism: ABA therapy,” she wrote.

She noted that the plan could have excluded all coverage of autism treatment, but once it did cover autism treatment it could not exclude the treatment.

The case is Doe v. United Behavioral Health et al, U.S. District Court, Northern District of California, No. 19-cv-07316.

For plaintiff: Caroline Reynolds, D. Brian Hufford and Jason Cowart of Zuckerman Spaeder

For UnitedHealth: Jennifer Romano, Kristin Madigan and Kimberley Johnson of Crowell & Moring

NOTE: This story has been updated to include a comment from UnitedHealth’s counsel.