Burke, A., Aplt. v. Independence Blue Cross
103 A.3d 1267
| Pa. | 2014Background
- Anthony Burke, a six-year-old with autism, seeks school-based ABA coverage under his family's Independence Blue Cross policy.
- Insurer denied school-based ABA due to a place-of-service exclusion; internal and external reviews upheld the denial (Dec. 2009 external review).
- Act 62 of 2008 requires autism coverage for those under 21; January 1, 2010, Act 62 applies to the policy; ABA is treatment under Act 62.
- February 2010 Burke filed a civil complaint seeking declaratory and injunctive relief, styled as an agency appeal under Act 62(k)(2), with stipulations of fact and certified record.
- Common Pleas Court (July 2011) held Act 62 voided the exclusion during Jan 1–July 1, 2010; ordered insurer to cover school-based ABA; Superior Court later sua sponte questioned jurisdiction.
- Supreme Court granted review to determine (a) whether Act 62 permits judicial review of denial, and (b) whether the Declaratory Judgments Act provides a proper route given a drafting error in Act 62(k)(2).
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Act 62(k)(2) allows judicial review of a denial's disapproval | Burke: statute creates an appeal right when denial is disapproved, regardless of timing. | Independence Blue Cross: text only permits appeals from disapproving denials; here the external review upheld denial. | Asymmetric text, but not plain ambiguity; remanded to address jurisdiction via Declaratory Judgments Act |
| Whether the Declaratory Judgments Act provides original jurisdiction despite Act 62 drafting issues | Section 708(b) permits broad relief; suits filed as declaratory/injunctive relief fit original jurisdiction. | Act 62(k)(2) controls appellate route; external review denial precludes original-jurisdiction action. | Common pleas could hear the merits under Declaratory Judgments Act; reversal of dismissal proper |
| Whether the case is justiciable and appropriately decided in court | Remedy sought is legally cognizable and timely given Act 62’s provisions. | Issues of mootness/standing/ripeness may foreclose relief; the case might be moot but public-importance exception applies. | Court retained jurisdiction and addressed merits; avoided mootness concerns due to public-importance and potential widespread impact |
Key Cases Cited
- Burke v. Independence Blue Cross, 620 Pa. 598 (Pa. 2013) (per curiam; framework for appellate review under Act 62)
- Focht v. Focht, 613 Pa. 48 (Pa. 2011) (pure questions of law; de novo review standard)
- Commonwealth v. Holmes, 593 Pa. 601 (Pa. 2007) (statutory interpretation and issues of law; standard of review)
- Stackhouse v. Pa. State Police, 574 Pa. 558 (Pa. 2003) (substance over form in determining jurisdiction)
- In re Gross, 476 Pa. 203 (Pa. 1978) (mootness/patient-rights considerations; illustrative precedent)