Insurance providers can be a pain in the you-know-what, especially when it comes to covering certain procedures or important services that people need to live their lives normally. If those procedures and services aren’t on the plan, then you’re in trouble. An even bigger problem erupts when a big company can decide what insurance covers versus what it doesn’t. Such is the case for a pair of Arizona parents who are embroiled in an enormous legal battle for the proper care of their autistic son. Their employer, Banner Health, shockingly won’t cover the costs.
When parents Micah and Laura Etter learned that their child was identified as having autism spectrum disorder, they wished only that he could one day lead a normal life without having to deal with the stigma many diagnosed with the behavioral issue must endure.
Although the news was difficult, the parents looked to an increasingly optimistic body of evidence that provided insight into the beneficial effects of applied behavioral analysis (ABA) therapy. This form of treatment is designed to treat each child as if their case is unique, thereby personalizing therapy and care. In 1999, ABA was endorsed by the U.S. Surgeon General, a huge win for advocates of the life-changing therapy.
ABA therapy Arizona technicians might handle children slightly different than technicians in New York or Washington, but the overall practice will be similar. The therapy can still differ from child to child, but parents should be prepared for that ahead of time, especially if they were referred by parents who found the therapy to be successful in dealing with their child’s behavioral disorder.
In 2008, Arizona passed legislation requiring insurance providers to cover ABA therapy. As did many parents before them, the Etters opted to use the treatment for their child. They noticed a great deal of improvement, and his behavior became more normal, more manageable, and less stressful for everyone.
When Micah graduated from medical school, his son could no longer remain on DES insurance. Consequently, Micah tried to place his son on Banner’s insurance policy. He quickly discovered that Banner wouldn’t cover him either. The reason seems bizarre: the law requiring insurance providers to grant this type of coverage exempts companies who are self-insured, and Banner is big enough to buy its own insurance–granting it a lot of power over what is covered and what isn’t. What surprised the parents was the type of institution that denied their son coverage otherwise guaranteed by Arizona law–a health care provider.
The Etters decided to bring the gargantuan company to court, alleging that Banner denied coverage after changing the underlying reasons for doing so. If true, it would mean that the company violated at least two federal laws, one of which bars insurance plans from providing care based on whether or not the service needed is for physical or mental health issues. The other law provides guidelines for health plan standards.
When the parents pushed Banner to cover their son, the company suggested coverage was denied because ABA therapy was considered too “experimental.” But after repeated attempts to provide the company’s executives with more information on the therapy, Micah Etter was contacted by the president of Banner himself, Peter Fine, who said that the denial “was not based on medical judgment or rescission of coverage” and therefore would not be externally reviewed.
Meanwhile, the child has regressed because he isn’t getting the therapy he needs, and the Etter family is attempting to obtain a court order to get Banner to nix the policy which says the needed therapy is experimental. Sadly, there is no word yet on the outcome.