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Schwarzenegger Administration Sued for Allowing Health Insurance Companies to Deny Autism Care
Date:7/1/2009

efused to pay for ABA on the grounds that it was "experimental" and that there was insufficient medical evidence to show that it was an effective treatment for autism. But the evidence supporting the efficacy of ABA is now overwhelming. The Centers for Disease Control and Prevention, the National Institute of Mental Health, and the United States Surgeon General all agree that behavioral interventions, such as ABA, are a critical component of any comprehensive autism treatment program.

According to the lawsuit, until March of this year, health care consumers were able to appeal an insurer's denial of ABA through the DMHC's Independent Medical Review ("IMR") system, in which a treatment denial is reviewed by a team of doctors that is unaffiliated with the insurance company that denied the treatment and independent of the DMHC.

The suit alleges that as the IMR doctors increasingly overturned insurer treatment denials, compelling the insurers to pay for ABA, insurers privately urged the DMHC to change its procedures and process the treatment denials through the DMHC's own internal grievance review system. Unlike the IMR system, in which independent doctors evaluate whether a treatment should be provided on the basis of whether it is medically necessary and effective, the grievance system is conducted by DMHC staff, who are not doctors and who simply defer to the insurers' determination of whether the claim is even covered by their health care policies.

"Health insurers want to re-write the law to benefit their bottom line and the regulators are holding the pen," said Pam Pressley, Consumer Watchdog's Litigation Director. "California's mental health laws are clear: doctors get to decide whether care is needed, not insurance company bureaucrats or government lawyers."

Consumer Watchdog has learned that the health insurance industry mounted a lobbying campaign to convince the Schwarzenegger Administration
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SOURCE Consumer Watchdog
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