FAQ Regarding the Anthem/ABA Class Action Lawsuit

The Arc of Indiana strives to provide families with accurate, up to date information regarding issues faced by individuals with intellectual and developmental disabilities (I/DD) and their families, including persons with autism spectrum disorders.  The autism and ABA related class action lawsuit filed against Anthem has been in the news and discussed on social media.  Parents have a lot of questions about the lawsuit and what it means for their child.  The following FAQ was written by the attorneys who filed the lawsuit to provide answers to frequently asked questions regarding the lawsuit.

For more information read and listen to:

Statement from The Arc on Anthem Class Action Lawsuit

A View into Insurance and ABA Therapy

  1. What is a class action?

A class action is a lawsuit in which one person (generally referred to as a class representative) brings claims on behalf of both herself and other similarly situated persons (generally referred to as class members) against a company that has allegedly engaged in a common course of unlawful conduct that impacted the entire group or class.

  1. Who is included in the suit?

The Court must certify this lawsuit as a class action before class members are included.  Kathi Pierce is the proposed class representative, and she seeks to represent the following class:  All individuals (1) who have been, are, or will be covered by an Anthem health plan through their employer on or after April 9, 2012; (2) who have or will have a child that is age seven or older; (3) whose child has been, is, or will be diagnosed with a pervasive developmental disorder; and (4) whose child has required, requires, or will require ABA therapy as part of a treatment plan approved by a treating physician.

Individuals must satisfy all four requirements to be class members.

Please note that the lawsuit is against Anthem Insurance Companies, Inc. and does not address similar policies by other insurance companies.

  1. What is Anthem being sued over?  

Ms. Pierce alleges that Anthem is violating a law known as the Employee Retirement Income Security Act (29 U.S.C. § 1132(a)) and Indiana’s Autism Coverage Mandate (Indiana Code § 27-8-14.2) by engaging in the following policies and practices:

  1. Limiting the number of hours of ABA therapy covered for non-medical reasons based on the purported availability of similar services in public schools to children age seven or older.
  2. Offering ABA therapy providers “take-it-or-leave-it” deals to temporarily and marginally increase the number of hours of therapy authorized in exchange for participants or beneficiaries giving up their right to appeal coverage denials.
  3. Reviewing and determining medical necessity of ABA therapy with the help of individuals who are not specialists in the treatment of pervasive developmental disorders
  4. How long will the litigation take?

Class actions are a complex form of litigation and often take several years to complete. Based on recommended timelines in the Southern District of Indiana, this case may be set for trial as late as December 2016.  The date for a trial may be further modified (and even further delayed) for various reasons.  Ms. Pierce and her counsel will work to prosecute the case in an expeditious manner, but much of the timing is out of their control.

  1. Will parents be compensated for their child’s lost progress due to the hours cut by Anthem?  

Ms. Pierce’s primary goal is to end Anthem’s allegedly unlawful coverage limitations.  She is seeking a court order requiring Anthem to cover medically-necessary ABA therapy that is included in a child’s treatment plan, as required by Indiana’s Autism Coverage Mandate.  The lawsuit does not seek compensation for a child’s lost progress.  We are, however, interested in talking with parents who have paid out-of-pocket for ABA therapy as a result of a coverage denial by Anthem.

  1. Will the children get therapy paid for by Anthem to make up for the therapy they lost?  

As noted above, Ms. Pierce’s primary goal is to have Anthem end its allegedly unlawful coverage limitations and start covering ABA therapy in full for all children who fall within the criteria outlined in the response to Question 2.  The lawsuit also seeks to recover any profits Anthem obtained as a result of the allegedly unlawful denials of coverage for ABA therapy.  If we are successful in obtaining that relief, proposed class members will be entitled to share in the recovery.

  1. What if my child is different?  Will I still benefit?

Any children who fall within the criteria outlined in the response to Question 2 will be entitled to relief if the Court certifies the case for class action treatment and Ms. Pierce and the class members prevail.  Children who do not fall within the criteria outlined in the response to Question 2 will not be entitled to obtain any relief from this lawsuit.

  1. Do you opt in or are all children affected included?

If the Court certifies the proposed class, all children who fall within the criteria outlined in the response to Question 2 will be included in the case automatically.  There is no need to opt in or take any other action at this time.  We will post any major updates on this case to http://tmdwlaw.com/anthem-denies-coverage-for-autism-treatment/.

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