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Burke v. Independence Blue Cross

Supreme Court of Pennsylvania

October 31, 2014

ANTHONY BURKE, BY HIS PARENT AND NATURAL GUARDIAN, JOHN BURKE, Appellant
v.
INDEPENDENCE BLUE CROSS, Appellee

Argued May 7, 2014

Page 1268

Appeal from the Judgment of Superior Court entered on August 13, 2012 at 2299 EDA 2011, reversing the order of July 19, 2011 in the Court of Common Pleas of Philadelphia County, Civil Division, at 2226 February term 2010. Appeal allowed July 11, 2013 at 552 EAL 2012. Trial Court Judge: Idee C. Fox, Judge. Intermediate Court Judges: Kate Ford Elliott, President Judge Emeritus, John T. Bender, Judge, Robert E. Colville, Judge.

For Anthony Burke, APPELLANT: David George Gates, Esq., PA Health Law Project.

For Independence Blue Cross, APPELLEE: Gerald J. Dugan, Esq., Dugan, Brinkmann, Maginnis & Pace; William H. Lamb, Esq., Maureen Murphy McBride, Esq., Lamb McErlane, PC.

For Members of the Pennsylvania House of Representatives, AMICUS CURIAE: Rodney A. Corey, Esq., Tara Lynn Smith, Esq., Nora Winkelman, Esq., PA House of Representatives.

For Dennis O'Brien, AMICUS CURIAE: A. Roy DeCaro, Esq., Gerald Austin McHugh Jr., Esq., Stephen Edward Raynes, Esq., Raynes McCarty.

For Autism Speaks, AMICUS CURIAE: Cheryl Ann Krause, Esq., Dechert LLP; Kate Williams Ericsson, Esq.

CASTILLE, C.J., SAYLOR, EAKIN, BAER, TODD, MCCAFFERY, STEVENS, JJ. MR. JUSTICE SAYLOR. Former Justice McCaffery did not participate in the decision of this case. Mr. Chief Justice Castille, Mr. Justice Eakin, Madame Justice Todd and Mr. Justice Stevens join the opinion. Mr. Justice Baer concurs in the result.

OPINION

Page 1269

MR. SAYLOR, JUSTICE

At issue in this case is whether an insured party may lodge an appeal to court from an administrative decision denying insurance benefits for autism-related services.

Appellant, a six-year-old boy diagnosed with an autism-spectrum disorder, was receiving applied behavior analysis (" ABA" ), a type of autism-related service, in his home. ABA was covered by his family's insurance policy with Appellee Independence Blue Cross (" Insurer" ). Appellant's family requested that Insurer cover similar ABA services to be provided at Appellant's elementary school beginning August 25, 2009. Insurer denied the request, pointing to a place-of-service exclusion in the policy which specified that no services would be covered if the care was provided at certain types of locations, including schools.[1] This decision was unsuccessfully appealed internally. The dispute was then submitted to an independent external review agency appointed by the Pennsylvania Department of Insurance. See 40 P.S. § 764h(k)(1). In December 2009, that agency upheld the denial based on the policy's place-of-service exclusion.

Meanwhile, the General Assembly passed Act 62 of 2008,[2] which, inter alia, requires that health insurance policies provide coverage for the treatment of autism-spectrum disorders. See 40 P.S. § 764h(a) (" A health insurance policy . . . covered under this section shall provide to covered individuals or recipients under twenty-one (21) years of age coverage . . . for the treatment of autism spectrum disorders." ). On January 1, 2010, that provision began applying to the insurance policy at issue in this case. There is no dispute that ABA services constitute treatment for Act 62 purposes.

In February 2010, Appellant filed a complaint in the court of common pleas, couched as a statutory appeal, albeit seeking declaratory and injunctive relief in the form of a ruling that the policy's place-of-service exclusion is null and void under Act 62, as well as an order directing Insurer to cover Appellant's medically necessary treatments. Insurer filed responsive pleadings and Appellant requested judgment on the pleadings. Thereafter, the parties agreed that the matter comprised an agency appeal pursuant to subsection (k)(2) of Act 62 (quoted in relevant part below). The parties additionally submitted a stipulation of facts. The court then received the certified record, briefing, and oral argument.

In July 2011, the common pleas court rendered its decision, noting first that, pursuant to the parties' stipulation, the only issue before it was whether Act 62 ...


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