Burke Ex Rel. Burke v. Independence Blue Cross
128 A.3d 223
Pa. Super. Ct.2015Background
- Anthony Burke, a minor with an autism spectrum disorder, sought coverage from Independence Blue Cross (IBC) for school-based Applied Behavior Analysis (ABA); IBC denied coverage citing a policy exclusion for services provided in schools.
- IPRO, the external review agency, upheld IBC’s denial before Act 62 took effect for Burke; Act 62 (40 P.S. § 764h) went into effect on January 1, 2010 and explicitly includes ABA as a covered rehabilitative treatment.
- The Burkes’ plan converted to a self-funded plan on July 1, 2010; the only disputed period is January 1–July 1, 2010 when Act 62 applied and the policy still covered Burke.
- The trial court held Act 62 required coverage of school-based ABA despite the policy’s place-of-service (school) exclusion; this court initially reversed on jurisdictional grounds but the Pennsylvania Supreme Court remanded, allowing declaratory relief under the Declaratory Judgments Act.
- On remand the Superior Court considered statutory construction: whether the specific ABA-coverage mandate in Act 62 overrides a general ‘‘care in a school’’ exclusion in an insurer’s policy, and concluded Act 62 controls, so IBC must cover in‑school ABA for the relevant period.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the case is moot because Burkes left IBC and sought only prospective relief | Burke: public‑importance exception applies; relief can resolve legal right and possible damages remanded | IBC: no live controversy; Burkes sought no out‑of‑pocket damages for the disputed period | Not moot—issue of great public importance and apt to evade review; court reaches merits |
| Whether the trial court’s limited record procedure was improper | Burke: declaratory action over statutory construction; factual issues (treatment plan, provider licensing) can be resolved on remand | IBC: trial should be de novo; record limitation prevented development of facts showing lack of statutory coverage prerequisites | Procedural form (declaratory action) is permissible; factual questions left to trial court on remand |
| Whether Act 62’s general‑exclusion clause (§ 764h(c)) permits insurers to exclude services provided in schools | Burke: specific mandate to cover ABA (a listed rehabilitative care) controls over the general exclusion; exclusion would eviscerate statute | IBC: the general exclusion applies to all services provided in listed settings, including schools, as a quality‑control measure | Held for Burke: specific statutory mandate (including school‑based ABA) prevails over general place‑of‑service exclusion; Act 62 requires coverage during the period at issue |
| Whether Act 62 must be read in pari materia with IDEA to limit coverage obligations | Burke: Act 62 independently mandates coverage and can coexist with IDEA without limiting insurer obligations | IBC: IDEA’s regime for school services shows federal/state interplay that should limit insurance obligations for in‑school services | Court: Act 62 and IDEA are not in pari materia here; Act 62’s insurance mandate can operate independently and shift some costs to insurers |
Key Cases Cited
- Burke v. Independence Blue Cross, 103 A.3d 1267 (Pa. 2014) (Supreme Court held insureds could seek declaratory relief despite statutory drafting error in Act 62)
- Pilchesky v. Lackawanna County, 88 A.3d 954 (Pa. 2014) (mootness doctrine and exception discussion)
- In re D.A., 801 A.2d 614 (Pa. Super. 2002) (exceptions to mootness; public‑importance and repetition doctrines)
- Forest Grove School Dist. v. T.A., 557 U.S. 230 (2009) (scope of IDEA and limits on requiring services at private schools)
- Commonwealth v. Webbs Super Gro Products, Inc., 2 A.3d 591 (Pa. Super. 2010) (statutory interpretation principles and reading statutory provisions together)
- Rendell v. Pa. State Ethics Comm’n, 983 A.2d 708 (Pa. 2009) (court’s approach to narrow, purely legal issues suitable for review)