Burke Ex Rel. Burke v. Independence Blue Cross
171 A.3d 252
Pa.2017Background
- Act 62 (2008) amended Pennsylvania insurance law to require certain group health policies to cover "treatment of autism spectrum disorders," including ABA, subject to a $36,000 annual cap and usual cost-sharing; the statute also states coverage is "subject to ... any other general exclusions or limitations." 40 P.S. § 764h(c).
- Anthony Burke, a child with an autism-spectrum disorder, received ABA prescribed to be provided in his parochial school; his family’s group policy (Independence Blue Cross) contained an express place-of-service exclusion denying benefits for care provided in schools.
- Insurer denied in‑school ABA, the denial was upheld on external review, and Burke sued seeking declaratory and injunctive relief; lower courts (trial court and a divided Superior Court) held the in‑school exclusion ineffective as to ABA coverage and remanded for damages/factual findings.
- Insurer appealed to the Pennsylvania Supreme Court, arguing the statute’s plain language permits application of general policy exclusions (including place-of-service exclusions) to limit mandated autism coverage.
- The Supreme Court held the statute is materially ambiguous about the scope of "any other general exclusions," applied statutory construction (including ejusdem generis), gave weight to the Insurance Department’s interpretation, and concluded in‑school place‑of‑service exclusions cannot bar coverage for ABA when doing so would eviscerate the statutory mandate.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Act 62’s "any other general exclusions or limitations" permits place‑of‑service exclusions to bar coverage for ABA in school | Burke: The statute mandates ABA (an environmentally sensitive therapy); excluding in‑school ABA nullifies the mandate and is inconsistent with legislative purpose | Insurer: The statutory phrase plainly allows general exclusions; a place‑of‑service exclusion is general and therefore valid | Held: The statute is materially ambiguous; exclusions that would substantially undermine the mandatory coverage (e.g., foreclosing ABA in school) are not permitted — the in‑school exclusion is ineffective as to ABA coverage |
| Role of administrative interpretation (Insurance Department notice) | Burke: Department guidance forbids exclusions that eliminate coverage for treatments specifically delineated (like ABA); agency view merits deference | Insurer: Agency notice conflicts with statutory text and merits little weight | Held: The Court found the Department’s interpretation persuasive and consistent with statutory construction principles; it gave the notice "some weight" though declined to resolve deference doctrines in depth |
| Whether coverage depends on availability of school/IDEA services (coordination of benefits) | Burke: § 764h(d.1) shows Legislature did not intend private coverage to turn on availability via IEP/IDEA; insurers remain responsible even if school-based services exist | Insurer: The IDEA and school-based services fulfill much of the need; the statute supplements, not supplants, school obligations | Held: The Court rejected the view that private coverage should be contingent on lack of school services and gave little weight to IDEA overlap; coordination provision does not relieve insurers of coverage obligations |
| Role of medical necessity and factual record in location determinations | Burke: ABA’s environmental component means school placement can be medically necessary | Insurer: Whether in‑school ABA is medically necessary is a fact‑bound inquiry and insurers may justify exclusions for monitoring/administration reasons | Held: Determination of medical necessity is fact‑specific; Court remanded for factfinding on whether ABA in school was medically necessary and what services/costs occurred during the stipulated period |
Key Cases Cited
- Norfolk S. Ry. Co. v. Pub. Util. Comm’n, 77 A.3d 619 (Pa. 2013) (rules of statutory construction apply when ambiguities exist)
- Office of Admin. v. Pa. Labor Relations Bd., 916 A.2d 541 (Pa. 2007) (administrative interpretations inconsistent with statute have limited weight)
- Ins. Fed’n of Pa., Inc. v. Com. Ins. Dep’t, 970 A.2d 1108 (Pa. 2009) (statutory mandates for insurance coverage are given effect in light of remedial purpose)
- A.S. v. PSP, 143 A.3d 896 (Pa. 2016) (context is critical in statutory construction)
- Moure v. Reaughle, 604 A.2d 1003 (Pa. 1992) (medical‑necessity determinations are fact‑intensive)
- Burke v. Independence Blue Cross, 128 A.3d 223 (Pa. Super. 2015) (intermediate appellate decision affirming invalidity of in‑school exclusion for ABA)