Federal Court Rules that UnitedHealth Illegally Denied Autism Treatment for Zuckerman Spaeder Client
A federal court has ruled that UnitedHealth’s exclusion of a primary Autism treatment violates the Mental Health Parity and Addiction Equity Act (Parity Act) and United’s fiduciary responsibilities under the Employee Retirement and Income Security Act (ERISA). The ruling is another significant win in Zuckerman Spaeder’s ongoing effort to hold health insurers accountable for systematic denials of behavioral health treatments.
The decision by the U.S. District Court for the Northern District of California is the result of a lawsuit brought by the firm on behalf of a mother (Jane Doe) whose son is diagnosed with Autism Spectrum Disorder and who received health coverage through an employer-funded plan. Despite claiming to cover Autism treatments, the UnitedHealth-administered plan explicitly excluded Intensive Behavioral Therapies (IBT) and Applied Behavior Analysis (ABA) – the core treatment for Autism patients. In 2016 and 2019, Jane Doe sought coverage for the cost of her son’s ABA treatment, but her requests were denied by UnitedHealth.
In a motion for partial summary judgment, Zuckerman Spaeder successfully argued that the insurer’s exclusion violates the Parity Act. As the court stated in its March 5th order, “the exclusion carves out and rejects from coverage a core treatment for Autism: ABA therapy. As Doe correctly highlights, there are no comparable medical/surgical exclusions in the [United-administered] Plan. Thus, the exclusion, which excludes coverage for the primary treatment modality for a mental health condition, violates the plain language of the statute.”
Further, the court rejected UnitedHealth’s argument in its cross-motion that it cannot be held responsible for the Parity Act violation because it was simply administering the terms of an employer-sponsored plan. According to the court’s ruling, ERISA “explicitly requires a fiduciary to apply a plan’s terms, but only if those terms do not violate ERISA…United Health cannot hide behind the plan terms, especially where ERISA imposes specific and independent duties on its fiduciaries to otherwise comply with the provisions of ERISA.”
“It is tremendously significant that the Court found this exclusion of coverage for the most widely-used Autism treatment -- to be illegal, and that the nation’s largest health insurer can be liable under federal law for enforcing it,” said partner Caroline E. Reynolds. “Because this exclusion has been in many United-administered plans for years, there are likely to be thousands of other children and families who have been similarly affected. United failed to put the interests of its beneficiaries first when making potentially life-changing coverage decisions.”
“This case has delivered another important ruling in our effort to fight widespread behavioral health discrimination among for-profit insurers,” said partner D. Brian Hufford. “In denying benefits, United frequently seeks to ‘hide behind’ the terms of employer-sponsored plans that it administers. This decision strongly supports our argument that an insurance company can be held legally responsible for enforcing plan terms that violate ERISA and the Mental Health Parity Act.”
Under the direction of Mr. Hufford, Ms. Reynolds and partner Jason S. Cowart, Zuckerman Spaeder has achieved numerous mental health-related wins, including the landmark Wit trial win in 2019, delivered multiple settlements, and is pursuing additional lawsuits against UnitedHealth and other insurers. The mental health effort is part of a national practice representing patients and health care providers in disputes with health insurance companies. The firm’s cases have received high-level support from former U.S. Representative Patrick Kennedy and the U.S. Department of Labor, which has filed four amicus briefs supporting Zuckerman Spaeder cases in the Second, Third, Fifth, and Eighth Circuit Courts of Appeals, with the firm obtaining successful decisions each time.
The case is Jane Doe v. United Behavioral Health, et. al., 4:19-cv-07316-YGR. Meiram Bendat of Psych-Appeal serves as co-counsel.