Burke v. Independence Blue Cross (majority)Annotate this Case
Anthony Burke was a child diagnosed with an autism-spectrum disorder. Throughout the first six months of 2010, Anthony and his family were covered by a group health insurance policy (the “Policy”) with Appellant, Independence Blue Cross (“Insurer”), maintained through Anthony’s father, John Burke’s employer. Initially, Anthony received “applied behavioral analysis” (ABA) treatment at home. In August 2009, before an Autism Coverage Law became effective relative to the Burkes’ coverage, the family requested benefits, under the Policy, for ABA services to be provided at the parochial elementary school attended by Anthony. Insurer denied coverage on account of an express place-of-services exclusion in the Policy delineating that services would not be covered if the care was provided in certain locations, including schools. In a motion for judgment on the pleadings, Mr. Burke argued that the place-of-services exclusion in the Policy was nullified, as it pertained to in-school services, by the Autism Coverage Law. The Pennsylvania Supreme Court found that the Pennsylvania Legislature intended to permit only general exclusions that would not substantially undermine the mandatory coverage requirement: “we simply do not believe that the Legislature intended to permit insurers to exclude coverage in the sensory-laden educational environment where children spend large portions of their days, or to require families to litigate the issue of medical necessity discretely in individual cases to secure such location-specific coverage for the treatment.” The Supreme Court affirmed judgment in favor of the Burkes, and that the Policy’s place-of-services exclusion was ineffective under the Autism Recovery Law.