Last updated: July 18. 2013 7:01PM - 382 Views
Ralph B. Davis
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PIKEVILLE — A McDowell family is taking on the state’s largest health insurance provider in federal court, alleging the insurer is failing to provide coverage for approved and necessary autism treatment.

Mitchell and Debbie Crum are suing Anthem Health Plans of Kentucky, saying the insurer has denied to pay for their child’s treatment at the Highlands Center for Autism.

According to the Crums’ complaint, applied behavior analysis is “the most common and recognized method of treating autism,” citing as evidence ABA’s acceptance by Medicaid, the Office of Personnel Management and Kentucky Law. ABA is also the method used by Highlands to treat its patients. However, the Crums say Anthem has denied coverage, saying ABA is “being educational in nature, not medically necessary.”

The Crums contend ABA is medically necessary, and cite state law that defines ABA as “habilitative or rehabilitative care.”

The Crums also note that Anthem’s health plans renewed after January 2011 expressly cover ABA as a treatment for autism, but say Anthem has continued to refuse coverage of the treatment, telling them “the therapy is ‘educational in nature’ and the services are ‘not provided by licensed providers.’”

The Crums are also seeking to have their complaint certified as a class-action lawsuit, which would bring others who have similarly been denied coverage into the lawsuit with them.

The Crums’ attorney, Robert R. Sparks, of the Covington firm Parry, Deering, Futscher & Sparks, said Thursday he has no way of knowing how large the resulting class of plaintiffs would ultimately be, but he says there are many cases dealing with failure to pay for ABA care of autism patients, and Anthem is not the only insured denying claims.

“There are a lot of cases against a lot of insurers,” Sparks said. “It seems to go through a progression of denials.”

The suit, filed this week, is expected to take “years instead of months” to litigate, Sparks said.

U.S. District Judge Karen K. Caldwell has been assigned to preside over the case.

Anthem has not yet filed a response to the Crums’ complaint.

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