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Suit alleges autism care routinely denied

July 1, 2009 12:00:00 AM PDT
A consumer watchdog group has filed a lawsuit against the California Department of Managed Health Care. The group alleges state regulators wrongfully allowed insurance companies to deny certain treatments for children with autism.Kristie Sepulveda-Burchit and her husband knew something was wrong when their son Aidan was about 2. But it would take doctors nearly a year to figure out Aidan is autistic. The difficulty with the diagnosis turned out to be nothing compared to the battle the family has waged ever since with their insurance company.

"Well, it was like, 'Well, we don't handle that, our medical authorization side doesn't handle that.' Then they shot you over to behavioral health, who said 'We don't handle that, let me put you on through top of the chain here,' who said 'We don't handle that,'" explained Sepulveda-Burchit.

Wednesday, the group Consumer Watchdog sued the California Department of Managed Health Care, alleging the agency and its director have allowed private health insurers to refuse to provide health care to autistic children like Aidan.

"The department responsible for overseeing many of the state's insurance companies has been siding with insurance companies and denying access to necessary autism care," said Jerry Flanagan, Consumer Watchdog.

Flanagan says insurers like Blue Cross, Kaiser and Blue Shield once relied on a panel of independent doctors to evaluate autistic children to determine whether a treatment called Applied Behavioral Analysis (ABA) was appropriate.

But when the panel continued to recommend the companies fund ABA, they allegedly persuaded the state agency to allow their own employees to do the evaluations. The result: ABA treatments are now routinely denied.

The insurers contend ABA is experimental, or educational, but not medical. Kate Mouvious, whose son is also named Aidan, was diagnosed with autism when he was 2 and a half years old.

"It's not just one treatment, it's not chemotherapy, it's not targeted," said Mouvious. "There are so many things you have to try and throw at autism and see what works. ABA is one of those things that works."

Parents suspect insurers are just trying to protect their bottom line from high long-term costs. But they say state law requires they fund the care even if they don't like it.

"Autism is a medical diagnosis and they should fund it," said Sepulveda-Burchit.

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