Healthcare Litigation

What does "health care reform" promising "access" to health care services really mean if children can be denied the medical care they need? California HMOs...

Californians, including those stricken by autism, and their parents and caregivers, expect regulators to enforce the law, not to side with insurance companies seeking to boost their profits by denying patients the care they need.

Consumer Watchdog Sues California Department of Managed Health Care for Permitting HMOs to Deny Treatments to Autistic Children after Secret Meetings Between State Employees and HMO Execs

Los Angeles Superior Court BS 121397

UPDATE: Court Issues Preliminary Ruling Holding Autism Treatment Denials, Agency Actions Illegal.

Several families of autistic children denied treatments by their health plans have won administrative appeals, in a sign that a recent court ruling scrutinizing regulators may be having an effect on the state's handling of the cases.

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LOS ANGELES, CA -- A lawsuit claiming the California Department of Managed Care improperly allowed health insurers to decline payment for autism treatments will proceed to trial after a Los Angeles County Superior Court judge rebuked the state in a preliminary ruling. A Consumer Watchdog representative said regulators should stop denying coverage on the grounds that ABA providers are certified not by the state but by a national board. Continuing to do so would risk legal damages, the advocacy group said in a statement. "The DMHC has to change its practices going forward, and the department should immediately reverse its previous denials," Pam Pressley, litigation director for Consumer Watchdog, said in a statement. "Gov. Schwarzenegger, a long-time and vocal supporter of the Special Olympics and developmentally disabled children, should require his regulators to abide by the law."

A lawsuit alleging state regulators allow insurance companies to deny necessary but expensive treatment for autistic children in violation of state law has enough merit to proceed to trial, a Los Angeles Superior Court judge has ruled. The lawsuit, filed in July by Santa Monica-based Consumer Watchdog, seeks to compel the California Department of Managed Health Care to order health plans to cover applied behavioral analysis (ABA) if a member complains the treatment was denied though it is deemed medically necessary and is provided by licensed personnel or under the supervision of licensed personnel.

A lawsuit seeking health care coverage for the use of applied behavioral analysis in the treatment of autism has been cleared for trial by the Los Angeles County Superior Court. Consumer Watchdog et. al. vs. California Department of Managed Health Care et. al. involves Kaiser Permanente’s denial of coverage for a child’s ABA treatment because the provider wasn’t licensed by the state. The Oakland, Calif.-based health maintenance organization cited regulations issued by the California Department of Managed Health Care as its reason for denying coverage for ABA treatment.

Santa Monica, CA – A Los Angeles County Superior Court judge issued a ruling finding that the Schwarzenegger Administration has illegally sided with health insurance companies that deny access to care for autistic children.  A memo circulated by the Schwarzenegger Administration to health insurers was also ruled to be an illegal “underground regulation” because it violated state law requiring a public process for changing insurance regulations.

Refusing to cover a costly behavioral therapy because the care provider lacks a state license violates California law, a Los Angeles County judge finds.

Consumer Watchdog President Jamie Court said the ruling was reason enough for Gov. Arnold Schwarzenegger to order the department to stop fighting the suit and start ordering insurers to provide the treatment to their autistic members. "For an administration that is so involved with the Special Olympics to not understand the harm it's causing every day that an autistic child doesn't get the care they need, is not only legally inexcusable, but morally reprehensible," Court said.

The lawsuit, filed by Consumer Watchdog in Los Angeles Superior Court, claims DMHC has permitted the denial of "critically needed, medically necessary" treatments. The advocacy group alleged Department Director Cindy Ehnes illegally permitted insurers to deny coverage for Applied Behavioral Analysis, a common autism treatment, in violation of the California Mental Health Parity Act. Also, DMHC improperly withheld public documents requested by Consumer Watchdog, it claims.