Pension & Benefits News Speech therapy exclusion not in violation of mental health parity law
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Friday, July 10, 2020

Speech therapy exclusion not in violation of mental health parity law

By Pension and Benefits Editorial Staff

A putative class action alleging that a group health plan violated the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) by excluding coverage for non-restorative speech therapy as a treatment for autism spectrum disorder (ASD) failed to state a plausible claim for relief and, thus, was dismissed by the federal district court in Massachusetts. The plan’s inclusion of generally applicable exclusions for habilitative services and non-restorative speech therapy undercut the complaint’s allegation that the plan facially excluded benefits for non-restorative speech therapy only for mental health conditions.

The named plaintiff, a five-year-old child, was diagnosed with ASD in 2017. On the recommendation of his physician, the child underwent speech therapy to treat his ASD. However, the claims administrator of his Employee Retirement Income Security Act-based health plan refused to cover the speech pathologist’s services, which totaled $1,790.00. The administrator based its decision on the following exclusions:

The following mental health (including Autism Spectrum Disorder (ASD) services)/substance-related and addictive disorders services are not covered:

  • Habilitative services, which are health care services that help a person keep, learn or improve skills and functioning for daily living, such as non-restorative ABA speech therapy;
  • Speech therapy for non-restorative purposes.

According to the claims administrator, in order for speech services to be covered, they had to be restorative; and to be considered restorative, the speech function must have been previously intact, which was not the case with the child here. The child’s parents appealed the denial, arguing that speech therapy was a medically necessary mental health service and that the plan’s restriction of covering only restorative speech therapy violated the MHPAEA. The claims administrator denied the appeal, and this suit followed.

MHPAEA. The MHPAEA requires group health plans that provide both mental health benefits and medical/surgical benefits to ensure that the treatment limitations applicable to the mental health benefits are no more restrictive than those applicable to the medical/surgical benefits. Disparate coverage is prohibited only among treatments in the same classification.

Allegations. The child (by and through his parents) filed suit against the plan, its sponsor, and its administrator, asserting that the plan violated the MHPAEA because: (1) there was no general exclusion for non-restorative treatment; (2) there was no special exclusion for non-restorative treatment that applied to medical and surgical conditions; and (3) the plan contained a “habilitative” exclusion that applied only to mental health services. According to the complaint, the only services that were subject to the non-restorative exclusion were those that were used to treat developmental health conditions such as ASD.

Defendants’ response. The defendants countered that the plan limited coverage to all speech therapy that was restorative, i.e., intended to regain a level of speech that was previously intact, and that the exclusion applied regardless of the type of condition that the speech therapy was intended to treat. The defendants also noted that the “Exclusions” section of the plan stated generally that the plan did not cover any expenses incurred for services, medical care, or treatment relating to speech therapy. According to the defendants, the plan’s language evinced “no differentiation between mental health benefits and medical/surgical benefits,” meaning that the non-restorative speech therapy exclusion applied to any type of mental health or medical/surgical condition.

Conclusions. As the defendants noted, the plan contained an “Exclusions” section that provided a blanket exclusion of all “[h]abilitative services for maintenance/preventive treatment.” The “Exclusions” section also included a separate exclusion for “[s]peech therapy for non-restorative purposes.” The plan expressly linked the habilitative services and non-restorative speech therapy exclusions, presenting the latter as an example of the former (i.e., excluding “[h]abilitative services, which are health care services that help a person keep, learn or improve skills and functioning for daily living, such as non-restorative ABA speech therapy”).

Neither the non-restorative speech therapy exclusion nor the habilitative services exclusion purported on its face to address only mental health benefits. Although the plan expressly acknowledged that the “habilitative services” exclusion applied to “mental health (including Autism Spectrum Disorder (ASD) services/substance-related and addictive disorders,” the plan’s simultaneous presentation of generically applicable exclusions for habilitative services and non-restorative speech therapy did not support the plaintiff’s allegation that the plan facially excluded benefits for non-restorative speech therapy only for mental health conditions. Accordingly, the court granted the defendants’ motion to dismiss.

SOURCE: N.R. v. Raytheon Co., (D. Mass.), No. 20-10153-RGS, June 9, 2020.

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