By JJ Conway
Years ago, I attended an American Bar Association Conference held in Beverly Hills, California. One of the speakers was Jay Foonberg, Esq., a marketing guru in the legal profession. Foonberg was a real character. He said a lot that day. One of the things I remember is that he referred to his law degree as a “magic carpet.” He carried the example even further saying that when he kneeled on it, it took him to places he could never imagine. I thought it was a funny line, maybe a bit wacky. As time has marched on, I am beginning to realize just how right Foonberg was. His magic carpet analogy just keeps coming back to me as I look back at some of our clients’ cases that shaped the law and served to help others in a tangible way.
Mayfield v. ASC Incorporated Health & Welfare Benefits Plan (E.D. Mich. 2007) was one such case. The case would have otherwise been a routine healthcare denial but for the person who brought it. Christopher J. Mayfield was a dynamic salesperson with an infectious enthusiasm for life. He brimmed with optimism and punctuated every observation with a huge smile and hearty laugh. As lawyers, we know there are some clients whose call we would take anywhere, anytime. Chris was one of those clients.
He and his wife, Liz, an impressive person in her own work life, had a son who was struggling during the early stages of his development. The child’s actions suggested that he was having difficulty communicating and making sustained eye contact.
The couple sought out help from the child’s medical providers. They were informed along the away that their son, in all likelihood, had autism spectrum disorder. The condition was on the rise, and statistically the number of cases among toddlers was growing rapidly– 1 out of 150, 1 out of 100, 1 out of 60.
Still, there was no known cause and no known cure.
The couple began researching treatment options and seeking out the advice of medical providers. What they found was that young children receiving a decades-old therapy known as Applied Behavioral Analysis — or ABA — showed progress in establishing improved communication abilities and independent living skills. For those children on the spectrum who were higher functioning, ABA held the promise to help those children’s functional abilities become almost indistinguishable from children without autism.
As promising as ABA therapy was, there was a dearth of treatment centers. And because the signs of autism tended to surface around 18 months, which coincided with the age for administering the Measles, Mumps, and Rubella (MMR) vaccine, the internet was awash in misinformation. This was a perfect setting for health insurers to exploit. Medical plans reflexively denied all claims for ABA therapy by labeling it “experimental” or “investigative.” That meant that ABA treatment, which was costly, could be denied under the general exclusions section that appear in all health insurance contracts.
The problem with this reason for the denial for the Mayfields was that they saw real gains in their son’s abilities. Their son’s ABA therapy, which sometimes involved 40 hours per week of intensive work, was showing real functional improvements. And the setting where the therapy took place was safe – it was kid-friendly but also had sufficient clinical controls and was overseen by top-notch physicians on staff with a major medical center.
The Mayfields also noticed what later became known as the “parking lot problem.” The cars in the ABA treatment center parking lots tended to be expensive cars suggesting that care was available for those with means, not those without. At the time, the cost for ABA therapy was as much as a year of college tuition with room and board — and there was no 529 plan to tap. In other words, without insurance coverage, parents were paying college-tuition size bills for therapy being provided to two-year-olds.
The Mayfields resolved to fight the denials and fight them hard. They asked me to go and observe the ABA treatment of their son. They set up interviews with ABA experts.
They made arrangements for me to receive a crash course on the therapy’s efficacy by doctors who provided me with studies and literature that would allow us to challenge the underlying basis for the denial. So, we went to heart of the denial — was ABA therapy really still in its experimental stages as the insurers alleged? There was so much research showing it was an established mainstream treatment that the old studies were embarrassingly shallow.
The Mayfield’s case was 100 percent evidence based. They kept it data-driven by design.
After all the internal administrative appeals, litigation, and ultimately a federal court hearing, Judge Anna Diggs Taylor’s order in their case was elegantly simple. She overruled the insurance company, threw out the exclusion as applied to ABA therapy, and ordered the treatment covered. She ruled the therapy was proven, mainstream, and effective. It was a brief, terse ruling. But this brief order was like throwing a stone in water, as it would have real implications for the rights of children with autism and their parents in the coming years.
The Mayfield case led to many cases seeking ABA therapy on both an individual and class-wide basis (which will be discussed in a future column). But the universal takeaway is that a
lawyer should listen and learn from their clients. No one knows a case better than the client, even a case involving purely medical evidence, and there is an extremely valuable knowledge base there.
The idea of listening, learning, and incorporating those ideas into a case makes for a winning strategy and rewarding lifelong relationship.
Mayfield v. ASC Incorporated Health & Welfare Benefits Plan (E.D. Mich. 2007) was one such case. The case would have otherwise been a routine healthcare denial but for the person who brought it. Christopher J. Mayfield was a dynamic salesperson with an infectious enthusiasm for life. He brimmed with optimism and punctuated every observation with a huge smile and hearty laugh. As lawyers, we know there are some clients whose call we would take anywhere, anytime. Chris was one of those clients.
He and his wife, Liz, an impressive person in her own work life, had a son who was struggling during the early stages of his development. The child’s actions suggested that he was having difficulty communicating and making sustained eye contact.
The couple sought out help from the child’s medical providers. They were informed along the away that their son, in all likelihood, had autism spectrum disorder. The condition was on the rise, and statistically the number of cases among toddlers was growing rapidly– 1 out of 150, 1 out of 100, 1 out of 60.
Still, there was no known cause and no known cure.
The couple began researching treatment options and seeking out the advice of medical providers. What they found was that young children receiving a decades-old therapy known as Applied Behavioral Analysis — or ABA — showed progress in establishing improved communication abilities and independent living skills. For those children on the spectrum who were higher functioning, ABA held the promise to help those children’s functional abilities become almost indistinguishable from children without autism.
As promising as ABA therapy was, there was a dearth of treatment centers. And because the signs of autism tended to surface around 18 months, which coincided with the age for administering the Measles, Mumps, and Rubella (MMR) vaccine, the internet was awash in misinformation. This was a perfect setting for health insurers to exploit. Medical plans reflexively denied all claims for ABA therapy by labeling it “experimental” or “investigative.” That meant that ABA treatment, which was costly, could be denied under the general exclusions section that appear in all health insurance contracts.
The problem with this reason for the denial for the Mayfields was that they saw real gains in their son’s abilities. Their son’s ABA therapy, which sometimes involved 40 hours per week of intensive work, was showing real functional improvements. And the setting where the therapy took place was safe – it was kid-friendly but also had sufficient clinical controls and was overseen by top-notch physicians on staff with a major medical center.
The Mayfields also noticed what later became known as the “parking lot problem.” The cars in the ABA treatment center parking lots tended to be expensive cars suggesting that care was available for those with means, not those without. At the time, the cost for ABA therapy was as much as a year of college tuition with room and board — and there was no 529 plan to tap. In other words, without insurance coverage, parents were paying college-tuition size bills for therapy being provided to two-year-olds.
The Mayfields resolved to fight the denials and fight them hard. They asked me to go and observe the ABA treatment of their son. They set up interviews with ABA experts.
They made arrangements for me to receive a crash course on the therapy’s efficacy by doctors who provided me with studies and literature that would allow us to challenge the underlying basis for the denial. So, we went to heart of the denial — was ABA therapy really still in its experimental stages as the insurers alleged? There was so much research showing it was an established mainstream treatment that the old studies were embarrassingly shallow.
The Mayfield’s case was 100 percent evidence based. They kept it data-driven by design.
After all the internal administrative appeals, litigation, and ultimately a federal court hearing, Judge Anna Diggs Taylor’s order in their case was elegantly simple. She overruled the insurance company, threw out the exclusion as applied to ABA therapy, and ordered the treatment covered. She ruled the therapy was proven, mainstream, and effective. It was a brief, terse ruling. But this brief order was like throwing a stone in water, as it would have real implications for the rights of children with autism and their parents in the coming years.
The Mayfield case led to many cases seeking ABA therapy on both an individual and class-wide basis (which will be discussed in a future column). But the universal takeaway is that a
lawyer should listen and learn from their clients. No one knows a case better than the client, even a case involving purely medical evidence, and there is an extremely valuable knowledge base there.
The idea of listening, learning, and incorporating those ideas into a case makes for a winning strategy and rewarding lifelong relationship.
––––––––
John Joseph (J.J.) Conway is an employee benefits and ERISA attorney and litigator and founder of J.J. Conway Law in Royal Oak.
John Joseph (J.J.) Conway is an employee benefits and ERISA attorney and litigator and founder of J.J. Conway Law in Royal Oak.
