When a child is diagnosed with autism, one of the most important steps parents take is securing the right treatment and therapy. Applied Behavior Analysis (ABA), speech therapy, occupational therapy, and other services can profoundly affect a child’s development and quality of life. Unfortunately, many families face a devastating obstacle: health insurance denials for autism treatment.
If your insurer refuses to cover autism-related care, you are not alone. Families across California encounter these denials despite state and federal laws requiring insurance companies to cover medically necessary autism treatments. Knowing your rights and next steps can make the difference in getting your child's care.
Why Health Insurance Denials for Autism Happen
Insurance companies often deny autism treatment coverage for reasons such as:
- Claiming treatment is not “medically necessary.” Even though doctors prescribe therapies, insurers may argue that certain treatments are experimental or unnecessary.
- Limiting coverage for ABA therapy. Some insurers attempt to impose arbitrary caps on hours or duration, even though children often need intensive treatment.
- Improper reliance on policy exclusions. Insurers may point to exclusions that conflict with California law.
- Administrative errors. Sometimes denials are based on paperwork issues, missed deadlines, or insufficient provider documentation.
In many cases, these denials are not valid and can be successfully appealed.
California Protections for Autism Treatment
California has some of the strongest protections in the country for families seeking autism treatment. Under California’s Mental Health Parity Act and subsequent laws, private health insurers must cover medically necessary treatment for autism spectrum disorder, including ABA therapy. In addition, federal law prohibits insurers from treating mental health conditions differently from physical health conditions.
This means that if your child’s doctor determines that treatment is necessary, your health insurance company is generally required to provide coverage. Denials that ignore medical evidence or violate parity laws may be unlawful.
Steps to Take After a Denial
If your health insurer denies your child’s autism treatment, here are steps you can take:
- Review the denial letter carefully. Insurers must provide a reason for their decision. Understanding their stated rationale is the first step in challenging it.
- Request records from your provider. Ensure you have documentation of medical necessity, including evaluations and treatment recommendations.
- File an appeal with your insurance company. Most insurers have internal appeal processes that you must exhaust before escalating your case.
- Seek an Independent Medical Review (IMR). In California, you can request an IMR through the Department of Managed Health Care (DMHC). This allows an outside medical professional to review your case and override the insurer’s denial if it lacks merit.
- Contact an attorney who focuses on health insurance denials. Insurance companies often have teams of lawyers working to deny valid claims. Having legal representation can help level the playing field and increase your chances of success.
Why Legal Help Matters
For more than three decades, our firm has been fighting health insurance companies on behalf of families across California. We understand the tactics insurers use to deny medically necessary care and know how to hold them accountable.
Whether your insurer is refusing ABA therapy, limiting treatment hours, or denying other autism-related care, you don’t have to fight this battle alone. Families have successfully overturned denials and obtained life-changing treatment for their children with the right legal support.
Los Angeles Area Autism Services Lawyer
If your health insurer has denied coverage for autism treatment, The Law Offices of Scott Glovsky can help. We’ve spent decades fighting insurance companies and getting policyholders the care they need. Contact us today at (626) 323-8351 to discuss your case and learn how we can help you move forward.