The case was originally filed May 8, 2013 in the U.S. District Court for the District of Oregon and the matter was certified as class action on December 24, 2013. A.F., et al., v. Providence Health Plan, U.S. District Court for the District of Oregon, 3:13-cv-00776-SI. The Plaintiffs were all dependents covered under group health plans issued by Providence and were all diagnosed with autism spectrum disorder. Providence denied their health reimbursement claims for Applied Behavioral Analysis therapy (“ABA”) under a provision in their health plan that excluded from coverage treatments that were related to developmental disabilities.
In August 2014, the Court resolved the first claim and ruled that federal and state law prohibited Providence from invoking or relying on the Developmental Disability Exclusion as a basis for denying claims for ABA or any other medically appropriate treatment for autism spectrum disorder.
Shortly thereafter, the State of Oregon’s Insurance Division wrote bulletins requiring coverage of ABA and also immediately rendered illegal dozens or even hundreds of policy limitations on mental health coverage for all Oregonians in the private insurance market. The Division re-wrote its mental health parity rules and, in effect, eliminated an exclusion the carriers had cited to refuse to cover mental health care for individuals with intellectual disabilities. As a result, health insurance companies in Oregon and large corporations with self-insured plans began covering ABA for their employees.
The case then turned to focus on what remedy the five families that had been denied care were entitled to receive. “We argued that Providence unjustly enriched itself by not paying for the care these children needed and instead invested and sat on that money” said Keith Dubanevich, attorney with Stoll Berne and for the Plaintiffs.
In November 2016, all parties agreed to mediation with The Honorable Paul De Muniz acting as mediator. During this mediation, Providence agreed to never use the Developmental Disability Exclusion, it agreed to pay $10,000 each to two families who led the case, and agreed to pay attorneys’ fees. The Honorable U.S. District Court Judge Michael Simon approved the settlement on March 14, 2017.
Josh Ross, co-managing shareholder of Stoll Berne said: “We are honored to have represented five amazing families whose steadfast determination to obtain the best treatment for their children allowed us to help not only them but every other family in Oregon that needs substance abuse or mental health treatment.”