Do Health Plans Make More Profit Even When Losing Shares to Autistic People?

Summary

In this video, Lucelmo Lacerda, an expert in autism and education, discusses the apparent contradiction between the success rate of families suing health plans for autism treatments and the record profits reported by those same health plans. He explains how health insurance companies frequently deny claims for essential autism therapies like ABA to cut costs, even though this leads to legal action. Lacerda emphasizes the importance of families pursuing their rights through legal channels to challenge these denials, ultimately hoping to shift the health plans' business model toward offering better, more affordable services.

Takeaways

• 😀 The news highlighted that autistic children are winning 9 out of 10 lawsuits against health insurance companies, signaling a significant legal trend.
• 😀 The increase in profits for health insurance companies in 2024 is seen as contradictory given the high number of lawsuits they are losing, sparking confusion about their actual financial situation.
• 😀 Health insurance companies often choose to deny treatment, hoping that only a small percentage of customers will take legal action, thus keeping costs low for them in the long run.
• 😀 The cost of denying treatment is often far greater than if the insurance company had simply provided the proper services, but they rely on the low percentage of claims to save money.
• 😀 The legal process for fighting these denials is difficult for many families, as most don't have the resources to pursue lawsuits, making it a challenge to access appropriate care.
• 😀 A key reason for health insurance companies’ success is their ability to offer subpar services under the guise of recognized therapies like ABA (Applied Behavior Analysis), making it hard for families to prove the inadequacy of the treatment.
• 😀 ABA therapy requires intensive, high-quality services, which is often not the case in many insurance-provided interventions, leading to the treatment being improperly labeled as ABA despite not meeting the required standards.
• 😀 The Brazilian legal system doesn't use punitive damages, which would make it more expensive for insurance companies to deny care to everyone, meaning that more families must resort to lawsuits to drive systemic change.
• 😀 The solution to improving the situation lies in more families entering lawsuits to force insurance companies to recognize their responsibility and provide the proper care, thus increasing the financial cost of denying services.
• 😀 The speaker encourages families to fight for their rights, even if it means navigating the complicated and expensive legal process, as this collective action will eventually pressure the industry to change.

Q & A

What is the main contradiction the speaker addresses regarding health insurance companies and autism treatments?

The speaker highlights the contradiction between health insurance companies losing 90% of legal cases related to autism treatments and their huge profits. While they deny coverage for treatments like ABA, they still manage to generate large profits.

Why do health insurance companies deny treatments for autism despite the legal battles they face?

Health insurance companies deny treatments like ABA because they calculate that the cost of denying treatment to most individuals is lower than the cost of providing appropriate treatment. They take advantage of the small percentage of individuals who pursue legal action.

What does the speaker mean by 'damaging punitive' legal action in other countries?

In other countries, punitive damages are applied when a company repeatedly violates the law or acts in bad faith, such as denying necessary treatments. This is meant to penalize companies and make it more expensive for them to engage in such practices.

How do health insurance companies manage to keep costs low despite the legal risks?

They rely on the fact that only a small percentage of people who are denied treatment actually take legal action. For those who do, the insurance company may end up paying more, but the overall cost is still lower than providing coverage to everyone who needs it.

What are the challenges families face when trying to sue health insurance companies for denied autism treatments?

Families face several challenges, including the difficulty in proving that the treatment they were offered was not legitimate ABA therapy. They also struggle with finding a specialized lawyer and the legal complexity involved in pursuing such cases.

What is ABA therapy, and why is it important for individuals with autism?

ABA (Applied Behavior Analysis) therapy is an evidence-based treatment for autism that requires intensive, structured, and individualized intervention. It is important because it helps improve behaviors and social skills in individuals with autism.

Why is it problematic when health insurance companies offer limited ABA therapy sessions?

Offering limited ABA sessions, such as only 50 minutes per week, is problematic because ABA therapy requires a much higher level of intensity and frequency to be effective. Additionally, professionals need extensive training to deliver the therapy correctly.

What role does the knowledge of specialized lawyers play in winning legal cases against health insurance companies?

Specialized lawyers with experience in autism and ABA therapy can help families present strong legal cases. They need to be able to research the correct standards of care and challenge insurance companies effectively, as proving the inadequacy of the offered treatments can be complex.

How does the speaker suggest addressing the issue of denied autism treatments by health insurance companies?

The speaker suggests that more families need to pursue legal action against health insurance companies to ensure their rights are recognized. As more cases are brought to court, the costs of denial will increase for insurance companies, which may prompt them to change their practices.

What is the broader societal impact of families pursuing legal action against health insurance companies for denied autism treatments?

The broader societal impact is that it can change the culture of health insurance companies and force them to provide more appropriate and adequate care. It also highlights the importance of securing access to essential health treatments, benefiting not only individuals but society as a whole.