December 8, 2015, Portland, Oregon -- The Marion County Circuit Court has issued an Order granting preliminary approval of a Settlement Agreement in the class action lawsuit, P.S. v Oregon Public Employees Benefits Board (PEBB), filed by the law offices of Megan Glor and Sirianni Youtz Spoonemore Hamburger on behalf of “P.S.,” a six year old girl with autism whose mother is an employee of the State of Oregon. P.S. sought coverage of Applied Behavior Analysis (ABA) therapy, a gold standard therapy to treat autism. The class includes any member of PEBB’s self-insured plans (the Providence Choice Plan and the Statewide Plan) who received ABA therapy to treat Autism Spectrum Disorder and incurred unreimbursed expenses.
This settlement follows numerous decisions and settlements in Oregon, Washington, and around the country directing health benefit plans to pay for coverage of ABA therapy as a treatment for autism – including bulletins issued by Oregon’s Insurance Division in November 2014.
In what may be the first of its kind in the nation, however, this settlement also includes $17,500 in compensation to resolve allegations that the State of Oregon violated the civil rights of P.S. and her family by denying coverage of ABA therapy solely because it was “related to Autism” – even though Oregon’s Mental Health Parity law has required coverage for treatment of autism since 2005. Providence Health Plans, acting as PEBB’s plan administrator, had issued denial letters stating that:
“Under Providence's Plan, services ‘related to developmental disabilities, developmental delays or learning disabilities’ are specifically excluded from coverage. Because ABA services are related to Autism Spectrum Disorder, they are therefore not benefits covered by your plan.”
In a separate class action lawsuit against Providence in U.S. District Court, A.F. v Providence, essentially identical conduct by Providence in its commercial group insurance policies was found to violate both Oregon and Federal Mental Health Parity laws in a landmark decision on August 8, 2014.
In this settlement agreement, the State of Oregon has also agreed to reimburse class members for expenses they incurred to pay for ABA therapy to treat autism spectrum disorder between January 1, 2010, and January 30, 2015. It is anticipated that all class members will be fully reimbursed, but if total claims exceed $400,000, payments will be prorated. However, if total claims are so large that class members would be reimbursed less than 60% of their actual expenses (e.g., if total claims exceed $666,667), then the settlement will automatically terminate barring an agreement to increase the limit to ensure sufficient compensation.
Coverage of ABA therapy is also ensured. In August 2014, shortly after this lawsuit was filed, the State of Oregon agreed to provide immediate coverage of ABA therapy for all plan participants, and under this settlement agreement the State of Oregon agrees to continue that coverage at least through January 1, 2022.
Paul Terdal, a volunteer autism advocate who assisted P.S. and her parents, and other class members, praised the settlement: “In this settlement, the State of Oregon is accepting responsibility to pay for the medically necessary autism treatment that it should have been covering all along, under the terms of its contract with its employees. I look forward to working with the Oregon Insurance Division to ensure that other health benefit plans also fulfill their contracts and reimburse policy holders for the medically necessary care that can really make a difference in the lives of individuals with autism.”
Megan Glor, who with Eleanor Hamburger represents the plaintiff class, adds, “If approved, this will be the first class-wide settlement in Oregon that ensures that class members – all dependents with ASD and their families – will be reimbursed for medically-necessary ABA therapy going back to the implementation of the federal Mental Health Parity Act.”
