We've been representing a very nice family here in Northern Virginia who had the courage to go toe to toe with Walmart and its lawyers after Walmart refused to pay for applied behavioral analysis (ABA) therapy for the family's child.
They asked us to help after all "internal appeals" to Walmart's health benefit plan committee failed. This family went through some pretty callous treatment throughout the process, including being mislead into not filing some claims by the claims people working for Walmart's health benefit plan.
We reviewed the Walmart health benefit plan and felt that the plan did cover ABA therapy but Walmart continuted to deny the claim.
We filed suit.
Walmart called the claim "frivolous" and hired lawyers two states to try to defeat this family.
Too bad for Walmart that we found in its own files that, before finally denying the claim they had hired a different law firm and asked their advice about paying for Applied Behavioral Therapy for autism. This smoking gun document was marked "privileged" and it was obvious it was never meant to see the light of day but they produced it to us when we requested the entire claim file under the federal law of ERISA.
The "outside" lawfirm carefully reviewed the records submitted with the claim, the health benefit contract itself, and told Walmart "pay the claim." The law firm even warned of the danger of a class action lawsuit for ABA treatment for autism if Walmart was denying others their benefits.
Walmart also had an independant medical review performed. The medical review told them to "pay the claim."
What did Walmart do?
It didn't tell the family about what its own lawyers had determined it needed to do to honor its contract. It didn't tell them what the medical reveiw told them either.
Walmart denied the claim again, putting the family through more misery and financial distress.
Shortly after we filed suit Walmart hired another set of lawyers. Shortly after that it paid 100% of every claim that it owed. Walmart then paid 100% of the family's legal bills after a motion was filed alledging that Walmart's claims handling of this case had been done in bad faith.
Oh, and one final slap in the face to Walmart employees who are caring for a child or other family member with autism:
Walmart has specifically excluded ABA therapy for autism from its coverage effective January 1, 2013.
What a great and caring company. To its employees who seek care for autism Walmart has said, effective January 1:
"sorry, we are never paying you - you are on your own. Good luck!"