Lawsuit Says Aetna Wrongly Caps Autism Benefits

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A class action lawsuit against Aetna Inc. claims the healthcare titan unjustly cut off benefits for autism treatment, violating federal health laws and California state guidelines.

Anna M. Sanzone-Ortiz, who receives healthcare coverage from Aetna through her employer, claims her son can only get 20 hours of behavioral health therapy for his autism, even though the recommended amount is 36 hours.

According to Sanzone-Ortiz, the limit violates the Federal Employment Retirement Income Security Act and the California Mental Health Parity Act.

One of Sanzone-Ortiz’ attorneys, Jordan M. Lewis of Kelley/Uustal, told news sources, “[Applied behavior analysis] is generally considered the gold standard for treating autism…We believe Anna and others like her should have a fair shot at a real decision as to what sort of hours per week are appropriate, instead of having what we think is an arbitrary cap.”

Also called ABA, Applied Behavior Analysis is a strategic form of autism treatment geared toward reading, living skills, social skills, academics, and other important social capabilities.

The suit points out that pro-ABA literature suggests no less than 30 hours of treatment per week for individuals with autism.

When Sanzone-Ortiz told Aetna hers son needed ABA treatment, the health provider capped the weekly hours at 20.

After appealing the company’s decision, Sanzone-Ortiz received written notice that Aetna found “insufficient scientific support to determine in advance the optimal frequency, duration or intensity of ABA needed for a particular individual.”

Sanzone-Ortiz then sought help from the California Department of Managed Mental Health Care, which increased her son’s treatment to 25 hours per week.

Now, Sanzone-Ortiz hopes to join forces with others who suffered the same setbacks from Aetna. She is seeking an order making Aetna pay for any medically necessary treatment for her son, including ABA, even if it exceeds the arbitrary 20-hours. She also seeks compensation for out-of-pocket expenses caused by the weekly cap.