Families who’ve had to go through courts to force insurance companies to cover their medical claims are making calls this week for the Oregon Insurance Division to fight harder on the public's behalf.
Paul Terdal has two autistic sons. They were prescribed applied behavior analysis (ABA) therapy eight years ago so they could function better in society.
But ABA therapy can cost $50,000 a year and a doctor with Terdal's HMO, Kaiser Permanente, told him it was not covered.
Terdal took his case through the insurance coverage appeals process and won. Families in similar situations noticed and asked him to help with their insurance denials from , Providence Health and .
Terdal agreed and made himself a thorn-in-the-side of insurance companies for years. For example, he would turn up at rate review meetings in 2012 to say that .
But Providence and the other insurance companies continued to refuse coverage, saying developmental disabilities were excluded or that ABA therapy was experimental.
Their denials came despite the Center for Disease Control and Prevention saying that ABA therapy encouraged “positive behaviors and has become widely accepted among health care professionals.”
There are even two Oregon laws that specifically require treatment for autistic children.
Eventually, Terdal and other families asked the Oregon Insurance Division to make companies cover ABA therapy. And the division did ask doctors to look at specific cases.
Those doctors overwhelmingly recommended the therapy be covered. But the division still did not mandate insurance companies to cover it.
In the end, the families fighting Providence took their case to court. In 2014, they won.
But it wasn't until last week that the Oregon Insurance Division fined Providence $100,000 over this issue.
Terdal says he's deeply concerned it .
“The next time some issue like this comes up, the next time an insurer starts doing something that is flat-out illegal, they need to be stopped in their tracks,” he said.
In a statement, Oregon Insurance Division spokesman Jake Sunderland said the agency waited for litigation to be resolved before finishing its investigation.
"That case was not settled until spring of 2017, hence the delay," wrote Sunderland. "The nature of the complaint is about claims processing. The party filing the claim is getting all of the services they are entitled to."
A similar case is still under review with the state.
Sunderland said that investigation is pretty much wrapped up.
"We are just waiting for the Federal Department of Labor to conduct its own investigation into the plan," he said.
A bill to give the Oregon Insurance Division stronger and more specific direction to enforce consumer complaints in a timely fashion was introduced in Salem this year.
But the effort died after heavy lobbying from insurance companies.
Copyright 2017 Oregon Public Broadcasting
