Burke, A. v. Independence Blue Cross, Aplt.
23 EAP 2016
Pa.Oct 5, 2017Background
- Anthony Burke, a minor with autism, received prescribed applied behavioral analysis (ABA) treatment in school; insurer Independence Blue Cross (IBC) denied coverage citing a policy exclusion for services provided in a school.
- Pennsylvania’s Autism Spectrum Disorders Coverage Law (40 P.S. § 764h) requires insurers to cover diagnosis and treatment of autism spectrum disorders (including ABA) for recipients under 21, subject to certain limits.
- Section 764h(c) states coverage is subject to copayments, deductibles, coinsurance, and "any other general exclusions or limitations" of the policy.
- The parties stipulated IBC’s exclusion applies to all services provided in a school and is not limited to autism treatment.
- The Superior Court affirmed (128 A.3d 223 (Pa. Super. 2015)); this opinion is Justice Mundy’s dissent from the Pennsylvania Supreme Court decision, arguing the statute is unambiguous and permits application of general policy exclusions to in-school ABA.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether § 764h(c) allows insurers to apply a general policy exclusion (school-based services) to deny mandated ABA coverage | Burke: Allowing the exclusion would eviscerate the statutory mandate to cover ABA in practice | IBC: § 764h(c) expressly permits application of "any other general exclusions" to autism coverage | Dissent (Mundy J.): § 764h(c) is plain and unambiguous; general exclusions (including school exclusions) may limit autism coverage; would reverse Superior Court |
| Whether the statute is ambiguous such that courts should apply canons of construction or consider legislative intent | Burke: Legislative intent and statutory context show the legislature intended coverage for ABA in schools; ABA’s environmental component makes it uniquely unsuitable for exclusion | IBC: Text is clear; no need to consult intent or canons | Dissent: No ambiguity exists; canons like ejusdem generis are inapplicable because statutory language is clear |
| Whether ABA is a unique medical service that cannot be treated "to the same extent as other medical services" under § 764h(c) | Burke: ABA’s reliance on environmental modifications makes it distinct and incapable of exclusion like other services | IBC: ABA is listed among rehabilitative services but still subject to the same general exclusions as other medical services | Dissent: Rejects uniqueness argument; statutory structure separates copay/deductible language from "any other general exclusions," showing exclusions apply broadly |
Key Cases Cited
- Warrantech Consumer Prods. Servs., Inc. v. Reliance Ins. Co. in Liquidation, 96 A.3d 346 (Pa. 2014) (statutes unambiguous on their face require no resort to canons or legislative intent)
- United States v. Turkette, 452 U.S. 576 (1981) (ejusdem generis is an aid to construction used only when statutory language is uncertain)
- Harrison v. PPG Indus., Inc., 446 U.S. 578 (1980) (canons of construction apply primarily where textual uncertainty exists)
- United States v. Powell, 423 U.S. 87 (1975) (discussing role and limits of ejusdem generis and other canons)
- Burke v. Independence Blue Cross, 128 A.3d 223 (Pa. Super. 2015) (Superior Court opinion affirming denial of in-school ABA coverage; discussed in dissent)