Between 2008 and 2014, four legal cases were brought before the Colombian courts demanding that Applied Behavior Analysis (ABA) be provided by various health insurance programs. These cases represented 18 different families of children with autism. The families who fought for the rights of their children to obtain this crucial, science-based, best practices therapy were successful and won their cases! The courts ordered the Health Insurance and District Health authorities to provide Applied Behaviour Analysis treatment (ABA) to the 18 families with children suffering from autism. These court cases are a valuable resource for parents of children with autism in other Spanish-speaking, South and Central American countries who currently fight for the rights of their children to receive Early Intensive Behavioral Treatment (EIBT), Applied Behaviour Analysis treatment (ABA), also referred to by the pioneer who first developed the intensive treatment protocol, Dr. O. I. Lovaas.
Relevant Issues:
El padre de un niño de 4 años diagnosticado con ASD solicitó a Cafesalud Entidad de Promoción de la Salud (EPS) pagar los gastos de ABA como tratamiento para el niño. La EPS se negó a autorizar pagos por tratamientos especializados para espectro autista en instituciones no akscritas a la EPS.
The father of a 4 year old child diagnosed with ASD had been paying for his son’s ABA therapy delivered by a private organization. The father requested Cafesalud Healthcare Promotion Entity (ESP) to pay for ABA expenses as treatment for his child. The EPS refused to authorize payments for specialized treatments for autism spectrum in institutions not affiliated to the EPS.
Status:
Si no hay un proveedor de servicios afiliado a Cafesalud Entidad de Promoción de la Salud (EPS) que proporcione terapia ABA de idénticas cualidades, especialización e idoneidad como la organización privada, el médico tratante debe ordenar que el tratamiento especializado tenga lugar en esa organización privada y la EPS debe pagar los gastos. La EPS a traves de FOSYGA recupera stodos los gastos.
If there is no service provider affiliated with Cafesalud Healthcare Promotion Entity (ESP) providing ABA therapy of identical qualities, specialization and suitability as the private organization, the treating doctor must order the specialized treatment to take place in that private organization and the EPS must pay for the expenses. The EPS through FOSYGA recovers all expenses.
Relevant Issues:
La madre de un niño de 8 años diagnosticado con autismo y severo retraso mental solicitó a Human Heart EPS y a la Secretaría de Salud del Distrito de Bogotá autorizar las terapias necesarias para su hijo. Los acusados declinaron el pago de las terapias que no están incluidas en el Plan Obligatorio de Salud (POS) y son de naturaleza experimental como la terapia ABA.
The mother of an 8 year old child diagnosed with autism and severe developmental delay solicited Human Heart EPS and the District Health Secretariat of Bogotá to authorize the therapies needed for her son. The defendants declined payment for therapies that are not included in the Compulsory Health Plan (POS) and are experimental in nature such as ABA therapy.
Status:
La Corte ordenó a Human Heart EPS que autorice la realización de todo el tratamiento integral, incluidas las terapias convencionales y no convencionales que el respectivo médico tratante le prescriba al menor, con el fin de brindarle un mejor desarrollo integral, de manera que le permita mejorar su calidad de vida acorde con su dignidad como persona. Estas terapias, incluyendo ABA, que pese a su novedad y menor conocimiento y aplicación por parte de la comunidad médica científica, se ha comprobad o que pueden ofrecer una razonable probabilidad de efectividad en el proceso de rehabilitación psicofísica de tales personas, además de una mejor relación con sus familias y con la sociedad.
The Court ordered Human Heart EPS to authorize the completion of all comprehensive treatment, including conventional and unconventional therapies prescribed by the treating physician to the child, in order to provide a better overall development to allow him to improve his quality of life with dignity as a person. These therapies, including ABA, which despite their novelty and lesser knowledge and application by the scientific medical community, have been proven or can offer a reasonable probability of effectiveness in the process of psychophysical rehabilitation of such people, as well as a better relationship with their families and with society.
Relevant Issues:
Seis expedientes fueron acumulados para que fuesen fallados en una sola sentencia, tras considerar que presentaban unidad de materia: la negación del correspondiente ESP de proveer terapias y / o el reembolso de los costos de las terapias (incluyendo ABA) prescritas por el médico tratante del menor diagnosticado con autismo, Down u otra condición neurológica.
Six cases were tried together to be ruled in a single sentence, after considering that they presented a singular subject matter: the corresponding ESP (Health Care Promotion Entity) denial of the delivery of therapies and/or the reimbursement of costs for the therapies (including ABA) prescribed by the medical doctor treating the minor diagnosed with autism, Downs or other neuro-developmental condition.
Status:
La Corte, a pesar de que el tratamiento de salud requerido en la action de tutelar no se encuentra contenido en el POS, por contender componentes educativos, ordena a la EPS correspondiente a cada caso que autorice el program de terapia integral (incluyendo terapias comportamentales tipo ABA) de acuerdo a lo ordenado por el medico tratante del niño en las instituciones que se encuentren dentro de su red de prestadores de servicios. En caso de no poder garantizar el tratamiento mediante su propia red de prestadores de servicios deberá contratar con una IPS que lo suministre a fin de proteger los derechos fundamentales del niño que no sean vulnerados.
The Court, although the health treatment required in the tutelary action is not contained in the Compulsory Health Plan (POS) because it contains educational components, orders the EPS corresponding to each case to authorize the comprehensive therapy program (including behavioral therapies such as ABA) as ordered by the treating physician of the child in the institutions that are within its network of service providers. In case of not being able to guarantee the treatment through its own network of service providers, it must contract with an IPS that provides it in order to protect the child in his/her fundamental rights from being violated.
Relevant Issues:
Los distintos demandantes, diez (10) en total, padres y madres de dependientes la mayoría de ellos niños diagnosticados con autismo, presentan acción en contra diferentes Entidad Portadora de Salud (EPS) del departamento del Atlántico por considerar sus hijos vulnerados en sus derechos fundamentales a la vida digna, a la salud, al tratamiento integral, a la igualdad, al mínimo vital, a la seguridad social y a la protección especial del menor, al no autorizar la práctica de terapias alternativas tipo ABA y de neuro-desarrollo que no están incluídas en el Plan Obligatorio de Salud (POS) ni en un Instituto Prestador de Salud (IPS) y son específicamente prescritas por médicos no adscritos a los varios EPS.
The various plaintiffs, ten (10) in total, parents of dependents, most of them children diagnosed with autism, present actions against different Health Care Providers (EPS) of the department of the Atlantic because they consider their children violated in their fundamental rights of dignity, health, integral treatment, equality, minimum life expectancy, social security and special protection of the child, by not authorizing the practice of alternative ABA and neuro-developmental therapies that are not included in the Mandatory Health Plan (POS) or in a Health Service Provider (IPS) and are specifically prescribed by physicians not affiliated with the various EPS.
Status:
La Corte ordena la E.P.S. de cada caso que evalúe y califique al menor por un equipo multidisciplinario de la E.P.S., a fin de determinar la pertinencia del servicio requerido. Dicho concepto deberá estar fundamentado en criterios técnicos o científicos y en ningún caso en argumentos de tipo administrativo. En el evento de que el concepto no cumpla con estos parámetros el tratamiento reclamado deberá ser autorizado.
The Court orders the E.P.S. of each case to evaluate and qualify the child by a multidisciplinary team of the E.P.S., in order to determine the pertinence of the service required. This evaluating procedure must be based on technical or scientific criteria and in no circumstace on administrative grounds. In the event that the evaluating procedure does not comply with these parameters, the claimed treatment must be authorized.