A.F. v. Providence Health Plan

300 F.R.D. 474, 87 Fed. R. Serv. 3d 417, 57 Employee Benefits Cas. (BNA) 2601, 2013 WL 6796095, 2013 U.S. Dist. LEXIS 180054
CourtDistrict Court, D. Oregon
DecidedDecember 24, 2013
DocketNo. 3:13-cv-00776-SI
StatusPublished
Cited by10 cases

This text of 300 F.R.D. 474 (A.F. v. Providence Health Plan) is published on Counsel Stack Legal Research, covering District Court, D. Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
A.F. v. Providence Health Plan, 300 F.R.D. 474, 87 Fed. R. Serv. 3d 417, 57 Employee Benefits Cas. (BNA) 2601, 2013 WL 6796095, 2013 U.S. Dist. LEXIS 180054 (D. Or. 2013).

Opinion

OPINION AND ORDER

MICHAEL H. SIMON, District Judge.

Plaintiffs AF. and AP. (collectively “Plaintiffs”) bring this putative class action against Defendant Providence Health Plan (“Providence”). Plaintiffs claim that Providence illegally denied coverage to Plaintiffs as members of Providence-issued group health plans in Oregon of the therapeutic technique of Applied Behavior Analysis (“ABA”). Plaintiffs move to certify a class under Fed.R.Civ.P. 23(b)(2). Dkt. 36. Plaintiffs seek injunctive and declaratory relief, asking the Court to enjoin Providence from denying coverage based on its Developmental Disability Exclusion and to issue a declaration stating that the Developmental Disability Exclusion violates applicable law. For the reasons discussed below, Plaintiffs’ motion for class certification is GRANTED.

BACKGROUND

Plaintiffs AF. and AP. are both insured as dependent-beneficiaries under group health plans in Oregon provided by Providence. AF. and AP. have both been diagnosed with Autism Spectrum Disorder and prescribed ABA therapy by their treating physicians. ABA therapy is an intensive behavior therapy that measures and evaluates observable behaviors. Evidence shows that ABA therapy may help autistic children with cognitive function, language skills, and adaptive behavior. Evidence also suggests that the benefits of ABA are significantly greater with early intervention for young autistic children. Providence currently denies all requests for coverage of ABA therapy.

In 2012, Providence denied a request by AF.’s parents for reimbursement for the expenses of ABA therapy. AF.’s parents appealed the initial denial, which Providence also denied. When AF.’s parents appealed a second time, Providence denied the second appeal and provided this explanation:

Under the language of the Oregon Group Member Handbook for Open Option Plans, services “related to developmental disabilities, developmental delays or learning disabilities” are specifically excluded from coverage under this plan. (See Group Member Handbook, at 43). There is no question that autism spectrum disorder is a “developmental disability” or involves “developmental delay,” and PHP [Providence Health Plan] here has so interpreted it, in this case as it has in other eases seeking ABA services for autism spectrum disorder. Because ABA services are related to autism spectrum disorder, they are therefore not benefits covered under the plan.

Declaration of Joshua L. Ross (“Ross Deck”) Ex. C at 9. Dkt. 41-3.

Also in 2012, Providence denied the request by AP.’s physician for authorization of ABA therapy to treat AP.’s autism. AP.’s parents appealed Providence’s denial, and Providence denied the appeal. Providence provided the following explanation, almost identical to the explanation provided to A.F., to AP.’s parents:

Under the language of the Oregon Group Member Handbook for Open Option Plans, mental health services “related to developmental disabilities, developmental delays or learning disabilities” are specifically excluded from coverage under this plan. (See Group Member Handbook, at 41). There is no question that autism spectrum disorder is a “developmental disability” or involves “developmental delay,” and Providence as the plan administrator here has so interpreted it, in this ease as it has in other cases seeking ABA services for autism spectrum disorder. Because ABA services are mental health services related to autism spectrum disorder, they are therefore not benefits covered under the plan.

Ross Deck Ex. D at 8. Dkt. 41-4.

Thus, in both cases, Providence denied coverage of ABA therapy because it is a service “related to developmental disabilities, developmental delays or learning disabilities.” Id. This exclusion (hereinafter, “the [478]*478Developmental Disability Exclusion”) is included in all of the group plan insurance contracts issued by Providence after 2007. The Developmental Disability Exclusion is listed in the member handbook given to all members that describes the governing terms of the insurance plans.

Providence issues two types of plans: “self-insured” group plans and “insured” group plans. Under a “self-insured” plan, the employer carries the risk of coverage. Under an “insured” plan, Providence carries the risk of coverage. Both the “self-insured” and “insured” plans are subject to Oregon law and the federal Employee Retirement Income Security Act (“ERISA”). 29 U.S.C. §§ 1001 et seq. Plaintiff and all potential class members are members of “insured” group plans. Providence is both the administrator of the plans and a fiduciary to all plan members. Providence is obligated to apply exclusions consistently and uniformly.

Providence uses diagnosis codes and current procedural terminology (“CPT”) codes to process members’ claims. The diagnosis codes for Autism Spectrum Disorder all start with 299. There is no CPT code for ABA therapy.

Although Providence’s group plans differ in terms of the specific benefits provided to group members, all of the group plan contracts issued after January 1, 2007 contain several identical provisions, including: (1) coverage for “Mental Health Services;” (2) a definition of “Mental Health Services” that includes coverage of autism; and (3) exclusion of coverage for “services related to developmental disabilities, developmental delays, or learning disabilities” (the Developmental Disabilities Exclusion). Providence denies coverage of ABA therapy under the Developmental Disabilities Exclusion for all group members under all group plans, regardless of whether the member seeks reimbursement for payments for ABA therapy or pre-authorization of coverage.

The Developmental Disabilities Exclusion is not the only exclusion Providence asserts it can rely on to deny coverage for ABA therapy. For example, Providence states that it also intends to deny claims for ABA therapy on the ground that ABA therapy is investiga-tional and experimental (hereinafter, “the Experimental Exclusion”). Providence, however, denied the ABA therapy claims of both A.F. and A.P. based solely on the Developmental Disability Exclusion. Providence asserts that its current position is to deny ABA therapy based on any and all potential bases for denial, including but not limited to, both the Developmental Disability Exclusion and the Experimental Exclusion.

Starting in 2007, Providence elected under Or.Rev.Stat. § 743.857(1) to be bound by an independent review organization (“IRO”) with respect to the statutorily mandated external review of denial of coverage. The IRO review process allows plan members to appeal the denial of benefits to an independent physician outside of the Providence system, who reviews the denial under the four statutorily prescribed areas of review: (1) “whether a course or plan of treatment is medically necessary,” (2) “whether a course or plan of treatment is experimental or investigational,” (3) “whether a course or plan of treatment that an enrollee is undergoing is an active course of treatment for purposes of continuity of care,” and (4) “whether a course or plan of treatment is delivered in an appropriate health care setting and with the appropriate level of care.” Or.Rev.Stat.

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Bluebook (online)
300 F.R.D. 474, 87 Fed. R. Serv. 3d 417, 57 Employee Benefits Cas. (BNA) 2601, 2013 WL 6796095, 2013 U.S. Dist. LEXIS 180054, Counsel Stack Legal Research, https://law.counselstack.com/opinion/af-v-providence-health-plan-ord-2013.