A brief synopsis of how TLCs methods to Discover the Story behind Health Insurance Denials for Autism led to justice for numerous families of autistic children. (The full story about this case by
TLC alum Scott Glovsky (07) can be found in the TLC Warrior magazine, Fall 2013. See www.triallawyerscollege.com, “Support TLC” tab.)
Six years ago, “Guillermo” walked into my office. He was agitated and trembling as he told me that Kaiser Foundation Health Plan, a not for profit health plan, had refused to provide his two-year-old autistic son with Applied Behavioral Analysis (ABA) the most effective treatment for autism. Because early intervention is crucial for autistic children, Guillermos desperation was palpable. Autism Spectrum Disorders (ASDs) are a group of developmental disorders which onset in early childhood and often cause significant social, communication, and behavioral challenges. There is no physiological test, like a blood test, to determine if someone has an ASD. Instead, doctors analyze a childs behavior and development to make a diagnosis. While there is no cure for ASDs, ABA is widely accepted as the most effective treatment.
Kaiser, like every other health insurance company in California, refused to provide ABA to its members with ASDs. Kaiser systematically denied ABA on the ground that it was not a medical service, was not provided by licensed medical providers, and was merely educational. I took Guillermos case, and others like it, and filed a class action against Kaiser to stop them from systematically denying ABA for children with ASDs.
When I started to work on the cases, I struggled to understand ASDs. Though defined above, it is difficult to understand what ASDs really are since their definition is amorphous. I realized I needed to discover the story of ASDs so that people within the insurance companies, in the medical profession, and on juries, can wrap their arms around what autism truly is. I worked with our TLC Local Working Group and we began by reversing roles with a three-year-old, non-verbal autistic boy. I started to learn the story when I was spinning around in circles as a three-year-old boy without making any eye contact. I discovered how scary, confusing, and overwhelming each day must be for children with autism. Without understanding the tremendous limitations caused by ASDs, one cannot fully appreciate the importance of ABA.
To further discover the story, I spent time with my autistic clients. I was completely overwhelmed with the chaos, stress, and lack of control in his house. Andrew spun in circles in the living room as his family repeatedly tried to stop him from injuring himself but Andrew still persisted. As Andrew rarely slept for more than a few hours at a time, his entire family seemed overwhelmed, sleep-deprived, beaten down, defeated, and helpless. I learned that getting through each day with an autistic child requires tremendous strength, courage, and perseverance. As a result, these families rarely have the strength and fortitude to mount a battle against a powerful insurance company to fight for ABA.
All of this work reminded me again that it is crucial to work up cases with TLC methods as soon as possible. The focus groups and reenactments led to new avenues of formal discovery, which led to the discovery of new information, which led to new focus groups and reenactments, expanding the sophistication and breadth of our case along the way. When I use TLC methods early in the case, and continue to employ the methods throughout the case, I approach trial with a much more refined and powerful story. The result?: after almost six years of work, Kaiser has finally agreed to change their policies and stop systematically denying ABA and speech therapy to children with ASDs. As part of the settlement, it has established a large fund to reimburse families that paid for ABA and speech therapy over the past eight years. In addition, the fund will provide millions of dollars for cutting-edge autism research at UCLA and UCSF. Once again, the power of TLC methods to better discover the story of these cases, the powerful help of tribe members, and all of our caring, made the world a little bit better.